Provider Demographics
NPI:1962432393
Name:CHUNG, ELAINE (OD)
Entity type:Individual
Prefix:DR
First Name:ELAINE
Middle Name:
Last Name:CHUNG
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 1:690 RIVER OAKS PKWY
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1905
Mailing Address - Country:US
Mailing Address - Phone:408-914-8839
Mailing Address - Fax:
Practice Address - Street 1:690 RIVER OAKS PKWY
Practice Address - Street 2:SUITE 20
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1905
Practice Address - Country:US
Practice Address - Phone:408-914-8839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12795TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1043345051OtherMEDICAL NPI GROUP
CAGSD005300Medicaid
CAGSD005300Medicaid
CASD0127951Medicare PIN