Provider Demographics
NPI:1932307840
Name:CHU, SOFIA (MD)
Entity Type:Individual
Prefix:
First Name:SOFIA
Middle Name:
Last Name:CHU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SOFIA
Other - Middle Name:
Other - Last Name:SISWANTO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:S WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02190-0001
Mailing Address - Country:US
Mailing Address - Phone:781-383-6261
Mailing Address - Fax:781-383-1084
Practice Address - Street 1:223 CHIEF JUSTICE CUSHING HWY STE 301
Practice Address - Street 2:
Practice Address - City:COHASSET
Practice Address - State:MA
Practice Address - Zip Code:02025-1391
Practice Address - Country:US
Practice Address - Phone:781-383-6261
Practice Address - Fax:781-383-1084
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA243007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110085302AMedicaid
001768901Medicare PIN