Provider Demographics
NPI:1942366133
Name:CHUN, STEPHEN RUSSELL (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:RUSSELL
Last Name:CHUN
Suffix:
Gender:M
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2414 SHATTUCK AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-2023
Mailing Address - Country:US
Mailing Address - Phone:510-843-1228
Mailing Address - Fax:510-524-1062
Practice Address - Street 1:2414 SHATTUCK AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704-2023
Practice Address - Country:US
Practice Address - Phone:510-843-1228
Practice Address - Fax:510-524-1062
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5835TLG152W00000X, 152WC0802X, 152WL0500X, 152WP0200X, 152WS0006X, 152WV0400X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Not Answered152WS0006XEye and Vision Services ProvidersOptometristSports Vision
Not Answered152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Not Answered152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD005835Medicaid
CASD005835Medicaid
CAT10136Medicare ID - Type Unspecified