Provider Demographics
NPI:1255351961
Name:CHEN, WEN Y (MD)
Entity type:Individual
Prefix:
First Name:WEN
Middle Name:Y
Last Name:CHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-1173
Mailing Address - Country:US
Mailing Address - Phone:618-259-0440
Mailing Address - Fax:618-258-4362
Practice Address - Street 1:200 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-1173
Practice Address - Country:US
Practice Address - Phone:618-259-0440
Practice Address - Fax:618-258-4362
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-079700207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1224820001OtherMEDICARE DME PTAN
IL1932378668OtherDME NPI
IL036079700Medicaid
IL1932378668OtherDME NPI
E55175Medicare UPIN