Provider Demographics
NPI:1275525644
Name:CHAN, GERALD DENNIS (OD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:DENNIS
Last Name:CHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:JERRY
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:360 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5088
Mailing Address - Country:US
Mailing Address - Phone:530-273-3190
Mailing Address - Fax:530-273-5541
Practice Address - Street 1:360 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5088
Practice Address - Country:US
Practice Address - Phone:530-273-3190
Practice Address - Fax:530-273-5541
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5832 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY49206YMedicaid
0366860001OtherGROUP MEDICARE NSC
YYY49206YOtherGROUP MEDICARE PIN
0366860001OtherGROUP MEDICARE NSC
YYY49206YOtherGROUP MEDICARE PIN