Provider Demographics
NPI:1235111436
Name:CHUNG, GRACE U (MD)
Entity type:Individual
Prefix:DR
First Name:GRACE
Middle Name:U
Last Name:CHUNG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 W. RED BANK AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096
Mailing Address - Country:US
Mailing Address - Phone:856-853-0900
Mailing Address - Fax:856-853-5838
Practice Address - Street 1:17 W. RED BANK AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-853-0900
Practice Address - Fax:856-853-5838
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05549000207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0463503000OtherAMERIHEALTH
NJ24034OtherAETNA US HEALTHCARE
NJ197180801Medicaid
NJ633461OtherBLUE SHIELD
NJ1971808Medicaid
NJ633461OtherBLUE SHIELD
NJ031181Medicare PIN