Provider Demographics
NPI:1790813640
Name:CHUNG, LILY (OD)
Entity Type:Individual
Prefix:DR
First Name:LILY
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 1:500 N. ATLANTIC BLVD.
Mailing Address - Street 2:UNIT 151
Mailing Address - City:MONTERY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91754
Mailing Address - Country:US
Mailing Address - Phone:626-458-2020
Mailing Address - Fax:626-458-2022
Practice Address - Street 1:500 N. ATLANTIC BLVD.
Practice Address - Street 2:UNIT 151
Practice Address - City:MONTERY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754
Practice Address - Country:US
Practice Address - Phone:626-458-2020
Practice Address - Fax:626-458-2022
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT11121T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111210Medicaid
CAOP11121Medicare ID - Type Unspecified
CASD0111210Medicaid
CAU85512Medicare UPIN