Provider Demographics
NPI:1558375592
Name:FAN, DEBBI K (OD)
Entity Type:Individual
Prefix:
First Name:DEBBI
Middle Name:K
Last Name:FAN
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 1:690 RIVER OAKS PKWY STE 20
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-3226
Mailing Address - Country:US
Mailing Address - Phone:408-502-7636
Mailing Address - Fax:
Practice Address - Street 1:690 RIVER OAKS PKWY STE 20
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-3226
Practice Address - Country:US
Practice Address - Phone:408-502-7636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12825T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist