Provider Demographics
NPI:1972598910
Name:CHEN, KONHSIN CONNIE WANG (OD)
Entity type:Individual
Prefix:DR
First Name:KONHSIN CONNIE
Middle Name:WANG
Last Name:CHEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:K.CONNIE
Other - Middle Name:
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2425 EAST ST., SUITE #4
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1925
Mailing Address - Country:US
Mailing Address - Phone:925-689-2852
Mailing Address - Fax:925-689-1966
Practice Address - Street 1:2425 EAST ST., SUITE #4
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1925
Practice Address - Country:US
Practice Address - Phone:925-689-2852
Practice Address - Fax:925-689-1966
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2016-12-01
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-04-11
Provider Licenses
StateLicense IDTaxonomies
CAOPT 6578 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0065780Medicare PIN