Basic Information
| Provider Information | |||||||||
| NPI: | 1134169139 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 16699 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926236699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Practice Location | |||||||||
| Address1: | 18344 CLARK STREET | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188819811 | ||||||||
| FaxNumber: | 8188811639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/27/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | A62866 | AR | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00A628660 | 01 | CA | BLUE SHIELD | OTHER | 00A628660 | 05 | CA | MEDICAID |