Provider Demographics
NPI:1003851809
Name:CHIANG, ALICE (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICE
Middle Name:
Last Name:CHIANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 MENDOCINO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4330
Mailing Address - Country:US
Mailing Address - Phone:707-528-7817
Mailing Address - Fax:707-528-1699
Practice Address - Street 1:1002 MENDOCINO AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4330
Practice Address - Country:US
Practice Address - Phone:707-528-7817
Practice Address - Fax:707-528-1699
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65091207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A650910Medicaid
CA00A650910Medicaid
CA00A650910Medicare PIN
CA4538850001Medicare NSC