Basic Information
| Provider Information | |||||||||
| NPI: | 1902165533 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | YIBO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2722 MERRILEE DR | ||||||||
| Address2: | STE 230 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220314400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7036984444 | ||||||||
| FaxNumber: | 7032600116 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 JOHN PAUL JONES CIR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 237082111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579532075 | ||||||||
| FaxNumber: | 7579535318 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 66958 | CT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 390200000X | 63177 | NY | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2085R0202X | 0101262299 | VA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 61377 | 05 | NY | MEDICAID |