Provider Demographics
NPI:1679641203
Name:LAURIE CHALKIN
Entity Type:Organization
Organization Name:LAURIE CHALKIN
Other - Org Name:WILD IRIS OPTOMETRIC GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPTOMETRIST OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:CHAIKIN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:510-538-3937
Mailing Address - Street 1:3717 CASTRO VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-4405
Mailing Address - Country:US
Mailing Address - Phone:510-538-3937
Mailing Address - Fax:
Practice Address - Street 1:3717 CASTRO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-4405
Practice Address - Country:US
Practice Address - Phone:510-538-3937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10195152WL0500X
CA7597152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision RehabilitationGroup - Single Specialty
No152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0101950Medicaid
CASD0101950Medicaid
CAU46607Medicare UPIN