Provider Demographics
NPI:1104977693
Name:CHOI, CONNIE (OD)
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:CHOI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 VICTORIA BAY
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94502-6522
Mailing Address - Country:US
Mailing Address - Phone:510-589-9758
Mailing Address - Fax:
Practice Address - Street 1:30600 DYER ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1717
Practice Address - Country:US
Practice Address - Phone:510-441-7403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-13
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12903T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0129030Medicare ID - Type Unspecified