=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972967982
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA KOBLIK CHEN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2016
-----------------------------------------------------
Last Update Date | 12/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 475 WASHINGTON BLVD
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-5287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-379-0282
-----------------------------------------------------
Fax | 310-439-3701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18601 FM 1431 STE 104 #1015
-----------------------------------------------------
City | JONESTOWN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78645-3222
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-379-0282
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | 01091921A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number | A153270
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 326799
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 04-46798
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | E-15800
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 39883
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | A153270
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | 2022039895
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 2084N0600X
-----------------------------------------------------
Taxonomy Name | Clinical Neurophysiology Physician
-----------------------------------------------------
License Number | T9657
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------