Provider Demographics
NPI:1063641538
Name:KWAN, JUSTIN TIMOTHY (OD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:TIMOTHY
Last Name:KWAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 N CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-4548
Mailing Address - Country:US
Mailing Address - Phone:847-647-0707
Mailing Address - Fax:847-647-1402
Practice Address - Street 1:7225 N CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-4548
Practice Address - Country:US
Practice Address - Phone:847-647-0707
Practice Address - Fax:847-647-1402
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2019-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011274152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management