Provider Demographics
NPI:1255323473
Name:CHAN, WAYNE KEN (OD)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:KEN
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 1:229 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-3724
Mailing Address - Country:US
Mailing Address - Phone:617-247-0012
Mailing Address - Fax:508-872-7091
Practice Address - Street 1:229 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-3724
Practice Address - Country:US
Practice Address - Phone:617-247-0012
Practice Address - Fax:508-872-7091
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-16
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3419152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0354333Medicaid
MA0354333Medicaid
MA440558Medicare ID - Type Unspecified