Provider Demographics
NPI:1003152695
Name:CHUNG, CALEB IAN (OD)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:IAN
Last Name:CHUNG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 NEWPARK MALL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-5252
Practice Address - Country:US
Practice Address - Phone:510-745-9030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-31
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14448TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist