Provider Demographics
NPI:1629730122
Name:FAN, WEN YING (OD)
Entity Type:Individual
Prefix:
First Name:WEN
Middle Name:YING
Last Name:FAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:COURTNEY
Other - Middle Name:WEN YING
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-468-7370
Mailing Address - Fax:
Practice Address - Street 1:1793 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:IMLAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48444-1342
Practice Address - Country:US
Practice Address - Phone:810-721-9411
Practice Address - Fax:810-721-9512
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005375152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist