Provider Demographics
NPI:1669537254
Name:CHU, KENNETH (OD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CHU
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 1:500 N ROSEMEAD BLVD
Mailing Address - Street 2:UNIT 11
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-2104
Mailing Address - Country:US
Mailing Address - Phone:415-892-9750
Mailing Address - Fax:
Practice Address - Street 1:2033 SANTA ROSA PLZ
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-6349
Practice Address - Country:US
Practice Address - Phone:707-544-0924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4514T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0118100Medicare ID - Type Unspecified
CAU89584Medicare UPIN