Provider Demographics
NPI:1245766989
Name:CHIN, ELYSIA (DO)
Entity Type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:CHIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8771
Mailing Address - Fax:
Practice Address - Street 1:2625 W ALAMEDA AVE STE 518
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4817
Practice Address - Country:US
Practice Address - Phone:818-843-9020
Practice Address - Fax:818-843-9021
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16767207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program