Provider Demographics
NPI:1164800488
Name:CYNTHIA W CHAO D O A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CYNTHIA W CHAO D O A PROFESSIONAL CORPORATION
Other - Org Name:CYNTHIA W. CHAO D O A PROFESSIONAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHAO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:562-961-3137
Mailing Address - Street 1:1540 W AVERILL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3924
Mailing Address - Country:US
Mailing Address - Phone:562-208-6642
Mailing Address - Fax:
Practice Address - Street 1:10861 CHERRY ST STE 109
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5400
Practice Address - Country:US
Practice Address - Phone:562-961-3137
Practice Address - Fax:562-961-3196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-07
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207V00000X
CA20A7343305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
H48657Medicare UPIN