Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204F00000X | Transplant Surgeon | 036141746 | IL |
N | 208200000X | Surgeon | 35085196 | OH |
N | 208600000X | Surgeon | 35085196 | OH |
NPI | 1235293622 |
---|---|
Provider Name | John J Fung |
First Address | Burr Ridge, IL 60527-7594 |
Second Address | Chicago, IL 60637-1447 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2006 |
Last Update Date | 24/03/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036141746 | IL STATE LICENSE (01) | IL |