Basic Information
Provider Information
NPI: 1003152695
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: CHUNG
FirstName: CALEB
MiddleName: IAN
NamePrefix:  
NameSuffix:  
Credential: O.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1335 MARTIN LUTHER KING JR WAY
Address2:  
City: BERKELEY
State: CA
PostalCode: 947091912
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 100 NEWPARK MALL
Address2:  
City: NEWARK
State: CA
PostalCode: 945605252
CountryCode: US
TelephoneNumber: 5107459030
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/31/2012
LastUpdateDate: 12/31/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000X14448TLGCAY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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