Basic Information
Provider Information | |||||||||
NPI: | 1891794723 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHU | ||||||||
FirstName: | GARY | ||||||||
MiddleName: | YIU-KIN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CHU | ||||||||
OtherFirstName: | YIU-KIN | ||||||||
OtherMiddleName: | GARY | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | O.D. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 930 COMMONWEALTH AVE | ||||||||
Address2: | SUITE 2A NEW ENGLAND EYE INSTITUTE | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6172622020 | ||||||||
FaxNumber: | 6172366323 | ||||||||
Practice Location | |||||||||
Address1: | 930 COMMONWEALTH AVE | ||||||||
Address2: | SUITE 2A NEW ENGLAND EYE INSTITUTE | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6172622020 | ||||||||
FaxNumber: | 6172366323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/21/2005 | ||||||||
LastUpdateDate: | 05/01/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3911 | MA | Y |   | Eye and Vision Services Providers | Optometrist |   |
ID Information
ID | Type | State | Issuer | Description | 324361 | 05 | MA |   | MEDICAID |