Provider Demographics
NPI:1528374246
Name:CHAN, TIFFANY LAUREN (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:LAUREN
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 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:
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:
Is Sole Proprietor?:No
Enumeration Date:2010-08-19
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2240152WL0500X
CA14113152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD044779000Medicaid
CACA237595Medicare UPIN
MD221820ZALTMedicare PIN