Provider Demographics
NPI:1164536165
Name:CHAN, MAMIE CASSANDRA (OD)
Entity Type:Individual
Prefix:DR
First Name:MAMIE
Middle Name:CASSANDRA
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5341 WYOMING BLVD NE
Mailing Address - Street 2:STE D
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3164
Mailing Address - Country:US
Mailing Address - Phone:505-717-2005
Mailing Address - Fax:505-312-7551
Practice Address - Street 1:5341 WYOMING BLVD NE STE D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3164
Practice Address - Country:US
Practice Address - Phone:505-821-8333
Practice Address - Fax:505-821-8335
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA4896Medicaid
NMU83281Medicare UPIN
NMA4896Medicaid