Provider Demographics
NPI:1467918854
Name:VAN, KHAI (OD)
Entity Type:Individual
Prefix:
First Name:KHAI
Middle Name:
Last Name:VAN
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 1:8535 MENARD AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-2660
Mailing Address - Country:US
Mailing Address - Phone:773-627-0223
Mailing Address - Fax:
Practice Address - Street 1:16205 HARLEM AVE STE B
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1682
Practice Address - Country:US
Practice Address - Phone:708-614-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011264152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist