Provider Demographics
NPI:1780207761
Name:CHANCHENCHOP, ALISA (DO)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:CHANCHENCHOP
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S CEDAR CREST BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5649 WYNNEWOOD DR STE 104
Practice Address - Street 2:
Practice Address - City:LAURYS STATION
Practice Address - State:PA
Practice Address - Zip Code:18059-1124
Practice Address - Country:US
Practice Address - Phone:610-262-6641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-25
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT020151208000000X
PAOS023067208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics