Provider Demographics
NPI:1689868978
Name:CHUNG, MARISA (OD)
Entity Type:Individual
Prefix:
First Name:MARISA
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:PO BOX 24DD5
Mailing Address - Street 2:WESTWOOD STATION
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 STEIN PLAZA
Practice Address - Street 2:SUITE I-340
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-0001
Practice Address - Country:US
Practice Address - Phone:310-825-3090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 13321152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWOP13321AMedicare PIN