Provider Demographics
NPI:1669466348
Name:FAN, JENNY (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
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 1:708 E 15TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5712
Mailing Address - Country:US
Mailing Address - Phone:972-509-8555
Mailing Address - Fax:972-509-8556
Practice Address - Street 1:708 E 15TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5712
Practice Address - Country:US
Practice Address - Phone:972-509-8555
Practice Address - Fax:972-509-8556
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-02-04
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
TX5903TG152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A4355Medicare PIN
U87179Medicare UPIN
TX8F0882Medicare PIN