Provider Demographics
NPI:1164431961
Name:CHONG, DEREK STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:STEPHEN
Last Name:CHONG
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 1:18015 64TH AVE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-2101
Mailing Address - Country:US
Mailing Address - Phone:209-402-7301
Mailing Address - Fax:
Practice Address - Street 1:90-01 QUEENS BLVD, 3RD FLOOR
Practice Address - Street 2:MACYS VISION EXPRESS
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373
Practice Address - Country:US
Practice Address - Phone:718-595-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006982-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist