Healthcare Provider Details

I. General information

NPI: 1154813525
Provider Name (Legal Business Name): JONATHAN CHEN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2018
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5380 ROSWELL RD
ATLANTA GA
30342-1916
US

IV. Provider business mailing address

5380 ROSWELL RD
ATLANTA GA
30342-1916
US

V. Phone/Fax

Practice location:
  • Phone: 404-250-1680
  • Fax:
Mailing address:
  • Phone: 404-250-1680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number9821
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT003194
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: