Healthcare Provider Details

I. General information

NPI: 1508953332
Provider Name (Legal Business Name): LESLIE L CHEN O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 01/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4475 UNIVERSITY AVE
SAN DIEGO CA
92105-1731
US

IV. Provider business mailing address

4475 UNIVERSITY AVE
SAN DIEGO CA
92105-1731
US

V. Phone/Fax

Practice location:
  • Phone: 619-521-2020
  • Fax: 619-521-2025
Mailing address:
  • Phone: 619-521-2020
  • Fax: 619-521-2025

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12792
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number12792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: