Provider Demographics
NPI:1508953332
Name:CHEN, LESLIE L (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:L
Last Name:CHEN
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 1:4475 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1731
Mailing Address - Country:US
Mailing Address - Phone:619-521-2020
Mailing Address - Fax:619-521-2025
Practice Address - Street 1:4475 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1731
Practice Address - Country:US
Practice Address - Phone:619-521-2020
Practice Address - Fax:619-521-2025
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12792152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508953332Medicaid
CAAS119ZMedicare PIN