Basic Information
| Provider Information | |||||||||
| NPI: | 1679991053 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | TINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1201 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761024413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173322020 | ||||||||
| FaxNumber: | 8173324797 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2014 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 036.145557 | IL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 125065018 | IL | N | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207W00000X | R9737 | TX | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 401702201 | 05 | TX | MEDICAID |