Provider Demographics
NPI:1093123721
Name:CHAN, JONATHAN (OD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:CHAN
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 1:18717 STEFANI AVE
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-8438
Mailing Address - Country:US
Mailing Address - Phone:562-537-8687
Mailing Address - Fax:
Practice Address - Street 1:2615 TUSCANY ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-4631
Practice Address - Country:US
Practice Address - Phone:951-268-3036
Practice Address - Fax:951-735-2864
Is Sole Proprietor?:No
Enumeration Date:2014-07-25
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14864TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist