Provider Demographics
NPI:1619085263
Name:CHA, IMOK (MD)
Entity Type:Individual
Prefix:DR
First Name:IMOK
Middle Name:
Last Name:CHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 HILL ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947
Mailing Address - Country:US
Mailing Address - Phone:415-898-7649
Mailing Address - Fax:415-898-0870
Practice Address - Street 1:250 BON AIR ROAD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904
Practice Address - Country:US
Practice Address - Phone:415-925-7174
Practice Address - Fax:415-898-0870
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73632207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G736321Medicaid
CA00G736321Medicaid
F80845Medicare UPIN