=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730591249
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC RAY CHEN D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/02/2014
-----------------------------------------------------
Last Update Date | 04/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3003 N 3RD STREET
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-288-9848
-----------------------------------------------------
Fax | 602-288-5486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3003 N 3RD STREET
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-288-9848
-----------------------------------------------------
Fax | 602-288-5486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 006835
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------