Provider Demographics
NPI:1578623062
Name:KAO, CHANNON W (OD)
Entity Type:Individual
Prefix:DR
First Name:CHANNON
Middle Name:W
Last Name:KAO
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 1:2112 SHATTUCK AVE.
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704
Mailing Address - Country:US
Mailing Address - Phone:510-644-0909
Mailing Address - Fax:510-540-5542
Practice Address - Street 1:2112 SHATTUCK AVE.
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94704
Practice Address - Country:US
Practice Address - Phone:510-644-0909
Practice Address - Fax:510-540-5542
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10272152W00000X
MA3781152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist