Provider Demographics
NPI:1275689804
Name:JENNY FAN, OD PA
Entity Type:Organization
Organization Name:JENNY FAN, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-262-4391
Mailing Address - Street 1:708 E 15TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5712
Mailing Address - Country:US
Mailing Address - Phone:972-509-8555
Mailing Address - Fax:
Practice Address - Street 1:708 E 15TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5712
Practice Address - Country:US
Practice Address - Phone:972-509-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5093TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178744201Medicaid
TX178744201Medicaid