Basic Information
| Provider Information | |||||||||
| NPI: | 1003919309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHESTER | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRUZ | ||||||||
| OtherFirstName: | KAREN | ||||||||
| OtherMiddleName: | ROSE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 22210 | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946232210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105354000 | ||||||||
| FaxNumber: | 5105354225 | ||||||||
| Practice Location | |||||||||
| Address1: | 3060 E 9TH ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5105355500 | ||||||||
| FaxNumber: | 5105354349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 08/06/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT8698T | CA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | FHC71087F | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER | 1124035159 | 01 | SITE NPI | OTHER | 3762136 | 01 | PIN | OTHER | 0647524 | 05 | CA | MEDICAID | ZZZ2979Z | 01 | CA | MEDICARE PROVIDER NUMBER | OTHER |