Healthcare Provider Details

I. General information

NPI: 1114378353
Provider Name (Legal Business Name): ASHLEY GREENAWALT CHUNG OD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 01/26/2022
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 LAWRENCE EXPY DEPT 486
SANTA CLARA CA
95051-5173
US

IV. Provider business mailing address

1934 CASTRO DR
SAN JOSE CA
95130-1715
US

V. Phone/Fax

Practice location:
  • Phone: 408-554-9830
  • Fax:
Mailing address:
  • Phone: 805-610-7026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33444
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: