Provider Demographics
NPI:1720077274
Name:CHAO, CYNTHIA W (DO A PROFESSIONAL CO)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:W
Last Name:CHAO
Suffix:
Gender:F
Credentials:DO A PROFESSIONAL CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 W AVERILL PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3924
Mailing Address - Country:US
Mailing Address - Phone:562-208-6642
Mailing Address - Fax:
Practice Address - Street 1:10861 CHERRY ST STE 109
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-5400
Practice Address - Country:US
Practice Address - Phone:562-931-3137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-18
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7343207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73430Medicaid
CA20A7343AMedicare ID - Type Unspecified
CA00AX73430Medicaid