Provider Demographics
NPI:1346313020
Name:CHASTAIN, DONNA LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:LEE
Last Name:CHASTAIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 N ST
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-3120
Mailing Address - Country:US
Mailing Address - Phone:559-875-1112
Mailing Address - Fax:559-875-1013
Practice Address - Street 1:1000 N ST
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-3120
Practice Address - Country:US
Practice Address - Phone:559-875-1112
Practice Address - Fax:559-875-1013
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA9522T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0095220Medicaid
CAU22646Medicare UPIN
CASD0095220Medicare ID - Type Unspecified