Provider Demographics
NPI:1174756142
Name:CHONG, SUE JIN (OD)
Entity type:Individual
Prefix:DR
First Name:SUE
Middle Name:JIN
Last Name:CHONG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:SUE
Other - Middle Name:JIN
Other - Last Name:CHOI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:204 S NURSERY RD
Mailing Address - Street 2:STE 168
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75060-3184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:204 S NURSERY RD
Practice Address - Street 2:STE 168
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75060-3184
Practice Address - Country:US
Practice Address - Phone:972-579-4646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-25
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7433152W00000X
OK2634152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist