Basic Information
Provider Information | |||||||||
NPI: | 1174720569 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHENG | ||||||||
FirstName: | MARINA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2512 WHEATON WAY | ||||||||
Address2: |   | ||||||||
City: | BREMERTON | ||||||||
State: | WA | ||||||||
PostalCode: | 983103399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607823661 | ||||||||
FaxNumber: | 3607823689 | ||||||||
Practice Location | |||||||||
Address1: | 2200 NW MYHRE ROAD | ||||||||
Address2: |   | ||||||||
City: | SILVERDALE | ||||||||
State: | WA | ||||||||
PostalCode: | 983837681 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3608301100 | ||||||||
FaxNumber: | 3608301283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2007 | ||||||||
LastUpdateDate: | 04/04/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 002409 | GA | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 208600000X | MD60271597 | WA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 002409 | 01 | GA | RESIDENT TRAINING PERMIT | OTHER |