Provider Demographics
NPI:1982263265
Name:CHEN, MINA (OD)
Entity Type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:CHEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 CARLSON AVE APT 332
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2801
Mailing Address - Country:US
Mailing Address - Phone:510-709-7294
Mailing Address - Fax:
Practice Address - Street 1:157 PETALUMA BLVD N
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-2904
Practice Address - Country:US
Practice Address - Phone:707-285-7475
Practice Address - Fax:707-285-7476
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV00895701152W00000X
CA34418TLG152W00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program