Provider Demographics
NPI:1336113794
Name:CHIN, JESSE (OD)
Entity Type:Individual
Prefix:DR
First Name:JESSE
Middle Name:
Last Name:CHIN
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 1:526 NEWFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-3746
Mailing Address - Country:US
Mailing Address - Phone:203-327-1511
Mailing Address - Fax:203-325-4479
Practice Address - Street 1:526 NEWFIELD AVE
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-3746
Practice Address - Country:US
Practice Address - Phone:203-327-1511
Practice Address - Fax:203-325-4479
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002602152W00000X
NYVUT006536152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02592923Medicaid
06871Medicare ID - Type Unspecified
C322G1Medicare PIN
U99264Medicare UPIN