Provider Demographics
NPI:1285785949
Name:CHI, JOO HAE (OD)
Entity type:Individual
Prefix:
First Name:JOO
Middle Name:HAE
Last Name:CHI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JOO
Other - Middle Name:H
Other - Last Name:SHIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5450 STANTON AVE
Mailing Address - Street 2:APT E
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-1721
Mailing Address - Country:US
Mailing Address - Phone:510-919-9902
Mailing Address - Fax:
Practice Address - Street 1:555 SHOPS AT MISSION VIEJO
Practice Address - Street 2:STE 30 SHOPS AT MISSION VIEJO
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691
Practice Address - Country:US
Practice Address - Phone:949-364-4010
Practice Address - Fax:949-364-4001
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT12986152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD129680Medicare ID - Type Unspecified