Provider Demographics
NPI:1366835928
Name:KWAN, STEPHEN (OD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:KWAN
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 1:9201 BIG HORN BLVD
Mailing Address - Street 2:OPTOMETRY DEPARTMENT
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-1240
Mailing Address - Country:US
Mailing Address - Phone:916-478-5580
Mailing Address - Fax:
Practice Address - Street 1:9201 BIG HORN BLVD
Practice Address - Street 2:OPTOMETRY DEPARTMENT
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-1240
Practice Address - Country:US
Practice Address - Phone:916-478-5580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-06
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15026152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist