Provider Demographics
NPI:1700042249
Name:CHAN, STEPHANIE SARA (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:SARA
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 1:2110 FOREST AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1469
Mailing Address - Country:US
Mailing Address - Phone:408-295-3433
Mailing Address - Fax:
Practice Address - Street 1:2110 FOREST AVE STE B
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1469
Practice Address - Country:US
Practice Address - Phone:408-295-3433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1956152W00000X
CA13587TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist