Healthcare Provider Details

I. General information

NPI: 1699171298
Provider Name (Legal Business Name): SARAH CHUNG O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2014
Last Update Date: 11/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11540 SANTA MONICA BLVD
LOS ANGELES CA
90025-7905
US

IV. Provider business mailing address

4690 PENINSULA POINT DR
SEASIDE CA
93955-6542
US

V. Phone/Fax

Practice location:
  • Phone: 310-473-5464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number15143
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number15143
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number15143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: