Provider Demographics
NPI:1104052364
Name:CHEA, BOPHANY (MD)
Entity type:Individual
Prefix:
First Name:BOPHANY
Middle Name:
Last Name:CHEA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 THOMAS JOHNSON DR STE 101
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4427
Mailing Address - Country:US
Mailing Address - Phone:301-694-0606
Mailing Address - Fax:301-662-6928
Practice Address - Street 1:87 THOMAS JOHNSON DR STE 101
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4427
Practice Address - Country:US
Practice Address - Phone:301-694-0606
Practice Address - Fax:301-662-6928
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-02
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD72552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics