Provider Demographics
NPI:1619002854
Name:CHAN, SUSANA (OD)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:
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 1:891 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4020
Mailing Address - Country:US
Mailing Address - Phone:401-331-7850
Mailing Address - Fax:401-274-4739
Practice Address - Street 1:891 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4020
Practice Address - Country:US
Practice Address - Phone:401-331-7850
Practice Address - Fax:401-274-4739
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0000032701OtherBRUE CROSS
RI9082077Medicaid
23-77354OtherUNITED HEALTHCARE
RI414188OtherBLUE CROSS
RI32425OtherNIEGHBORHOOD HEALTH PLAN
RI9082077Medicaid