Provider Demographics
NPI:1598843765
Name:CHAN, SANDY S (OD)
Entity Type:Individual
Prefix:
First Name:SANDY
Middle Name:S
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2211 MOORPARK AVE STE 200
Mailing Address - Street 2:C/O WILLIAM ELLIS MD
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2632
Mailing Address - Country:US
Mailing Address - Phone:408-255-7785
Mailing Address - Fax:
Practice Address - Street 1:2855 STEVENS CREEK BLVD
Practice Address - Street 2:STE 2271
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-6709
Practice Address - Country:US
Practice Address - Phone:408-249-0705
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9521T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU25953Medicare UPIN