Provider Demographics
NPI:1093024176
Name:CHONG, CHRISTINE (OD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:
Last Name:CHONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:
Other - Last Name:WAHLSTEDT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:509-734-2511
Mailing Address - Fax:509-734-1632
Practice Address - Street 1:291 N MILWAUKEE ST STE A-3
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9132
Practice Address - Country:US
Practice Address - Phone:208-297-7019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2022-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60369639152W00000X
IDODP-100272152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist