Provider Demographics
NPI:1225461981
Name:CHAN, KEVIN (OD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
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 1:8100 BOONE BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:TYSONS CORNER
Mailing Address - State:VA
Mailing Address - Zip Code:22182-2629
Mailing Address - Country:US
Mailing Address - Phone:703-991-2766
Mailing Address - Fax:
Practice Address - Street 1:8100 BOONE BLVD STE 150
Practice Address - Street 2:
Practice Address - City:TYSONS CORNER
Practice Address - State:VA
Practice Address - Zip Code:22182-2629
Practice Address - Country:US
Practice Address - Phone:703-991-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2733152W00000X
VA0618002281152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist