Provider Demographics
NPI:1225117286
Name:CHAN, SELINA P (OD)
Entity Type:Individual
Prefix:
First Name:SELINA
Middle Name:P
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 1:9301 TAMPA AVE
Mailing Address - Street 2:#62
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-2503
Mailing Address - Country:US
Mailing Address - Phone:818-885-7215
Mailing Address - Fax:818-709-2292
Practice Address - Street 1:1689 ARDEN WAY
Practice Address - Street 2:STE 1344
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-4030
Practice Address - Country:US
Practice Address - Phone:916-922-5666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10879152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU72523Medicare UPIN