Provider Demographics
NPI:1407508385
Name:CHAN, KWOK FUNG (OD)
Entity Type:Individual
Prefix:
First Name:KWOK FUNG
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:RICKY
Other - Middle Name:KF
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:2650 JAMACHA RD STE 155
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92019-4319
Mailing Address - Country:US
Mailing Address - Phone:619-670-6296
Mailing Address - Fax:
Practice Address - Street 1:2650 JAMACHA RD STE 155
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92019-4319
Practice Address - Country:US
Practice Address - Phone:619-670-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-22
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist