Provider Demographics
NPI:1790830925
Name:CHIN, BRUCE DARRELL (OD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DARRELL
Last Name:CHIN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5050 LAGUNA BLVD STE 113
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4151
Mailing Address - Country:US
Mailing Address - Phone:916-684-7070
Mailing Address - Fax:916-684-8048
Practice Address - Street 1:5050 LAGUNA BLVD STE 113
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4151
Practice Address - Country:US
Practice Address - Phone:916-684-7070
Practice Address - Fax:916-684-8048
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8208T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0082080Medicaid
CAU01709Medicare UPIN
CAEP591ZMedicare PIN