Provider Demographics
NPI:1629393830
Name:CHUA, IAN CHARLSTON
Entity Type:Individual
Prefix:
First Name:IAN CHARLSTON
Middle Name:
Last Name:CHUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 BAROSSA DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4675
Mailing Address - Country:US
Mailing Address - Phone:650-776-9456
Mailing Address - Fax:
Practice Address - Street 1:725 WELCH RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1601
Practice Address - Country:US
Practice Address - Phone:650-497-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA117682208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program