1821140534 NPI number — DR. JENIFER KENI KEIKO ISHIZAKI CHUNG O.D.

Table of content: DR. JENIFER KENI KEIKO ISHIZAKI CHUNG O.D. (NPI 1821140534)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821140534 NPI number — DR. JENIFER KENI KEIKO ISHIZAKI CHUNG O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHUNG
Provider First Name:
JENIFER
Provider Middle Name:
KENI KEIKO ISHIZAKI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821140534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4501 SAND CREEK RD
Provider Second Line Business Mailing Address:
EYECARE CLINIC- OPTOMETRY
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94531-8687
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3400 DELTA FAIR BLVD
Provider Second Line Business Practice Location Address:
EYECARE CLINIC-OPTOMETRY
Provider Business Practice Location Address City Name:
ANTIOCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94509-4004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-779-4378
Provider Business Practice Location Address Fax Number:
925-779-5421
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  550 , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 11660 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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