Provider Demographics
NPI:1477582849
Name:CHENG, MARY MINAH
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:MINAH
Last Name:CHENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8622 E GARVEY AVE #101
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770
Mailing Address - Country:US
Mailing Address - Phone:626-288-1287
Mailing Address - Fax:626-288-3229
Practice Address - Street 1:8622 E GARVEY AVE #101
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770
Practice Address - Country:US
Practice Address - Phone:626-288-1287
Practice Address - Fax:626-288-3229
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 127820 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0127820Medicaid
CASD0127820Medicaid
CA2011736Medicare UPIN