Provider Demographics
NPI:1588216519
Name:CHUNG, NELLIE (OD)
Entity Type:Individual
Prefix:
First Name:NELLIE
Middle Name:
Last Name:CHUNG
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 1:1046 NW JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209
Mailing Address - Country:US
Mailing Address - Phone:503-944-5567
Mailing Address - Fax:503-944-5471
Practice Address - Street 1:1046 NW JOHNSON ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3161
Practice Address - Country:US
Practice Address - Phone:503-944-5567
Practice Address - Fax:503-944-5471
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-10
Last Update Date:2023-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60961378152W00000X
ORATI4496152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORATI4496OtherOR STATE LICENSE