Healthcare Provider Details

I. General information

NPI: 1558282160
Provider Name (Legal Business Name): JERRY ULLAH CHAUDHRY OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4092 S CANAL WAY
ONTARIO CA
91761-3903
US

IV. Provider business mailing address

4092 S CANAL WAY
ONTARIO CA
91761-3903
US

V. Phone/Fax

Practice location:
  • Phone: 774-578-9547
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTA3163
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: