Provider Demographics
NPI:1912973074
Name:CHEN, JEFF TAI LI (DR)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:TAI LI
Last Name:CHEN
Suffix:
Gender:M
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 NORTH STAR WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-9262
Mailing Address - Country:US
Mailing Address - Phone:209-342-2300
Mailing Address - Fax:209-342-2300
Practice Address - Street 1:2450 ASHBY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2067
Practice Address - Country:US
Practice Address - Phone:510-204-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A909000Medicaid
CA00A909000Medicare ID - Type Unspecified
CA00A909000Medicaid