Provider Demographics
NPI:1780626986
Name:CHEN, EDWIN (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:
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 1:12395 EL CAMINO REAL
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-3082
Mailing Address - Country:US
Mailing Address - Phone:858-793-0093
Mailing Address - Fax:
Practice Address - Street 1:12395 EL CAMINO REAL
Practice Address - Street 2:SUITE 300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3082
Practice Address - Country:US
Practice Address - Phone:858-793-0093
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD26595207W00000X
CAA101572207W00000X
PAMD437604207W00000X
NJ25MA08624900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA08624900OtherLICENSE
PAMD437604OtherLICENSE