Provider Demographics
NPI:1235181165
Name:WAN, KEITH MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MICHAEL
Last Name:WAN
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 1:10549 SCRIPPS POWAY PKWY
Mailing Address - Street 2:STE G
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-3963
Mailing Address - Country:US
Mailing Address - Phone:858-530-2800
Mailing Address - Fax:858-530-2889
Practice Address - Street 1:10549 SCRIPPS POWAY PKWY
Practice Address - Street 2:STE G
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92131-3963
Practice Address - Country:US
Practice Address - Phone:858-530-2800
Practice Address - Fax:858-530-2889
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10924T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU81650Medicare UPIN
CAW15031Medicare ID - Type Unspecified