Provider Demographics
NPI: | 1003919309 |
---|---|
Name: | CHESTER, KAREN ROSE (OD) |
Entity Type: | Individual |
Prefix: | |
First Name: | KAREN |
Middle Name: | ROSE |
Last Name: | CHESTER |
Suffix: | |
Gender: | F |
Credentials: | OD |
Other - Prefix: | |
Other - First Name: | KAREN |
Other - Middle Name: | ROSE |
Other - Last Name: | CRUZ |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 22210 |
Mailing Address - Street 2: | |
Mailing Address - City: | OAKLAND |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94623-2210 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 510-535-4000 |
Mailing Address - Fax: | 510-535-4225 |
Practice Address - Street 1: | 3060 E 9TH ST |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | OAKLAND |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94601-2905 |
Practice Address - Country: | US |
Practice Address - Phone: | 510-535-5500 |
Practice Address - Fax: | 510-535-4349 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-09-06 |
Last Update Date: | 2013-08-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | OPT8698T | 152W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 152W00000X | Eye and Vision Services Providers | Optometrist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | FHC71087F | Other | MEDI-CAL PROVIDER NUMBER |
1124035159 | Other | SITE NPI | |
3762136 | Other | PIN | |
CA | 0647524 | Medicaid | |
CA | ZZZ2979Z | Other | MEDICARE PROVIDER NUMBER |
CA | 0647524 | Medicaid |