Provider Demographics
NPI:1710021274
Name:WILLIAM FAN, OD PA
Entity Type:Organization
Organization Name:WILLIAM FAN, OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:972-262-4391
Mailing Address - Street 1:625 W DICKEY RD
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3129
Mailing Address - Country:US
Mailing Address - Phone:972-262-4391
Mailing Address - Fax:972-264-6135
Practice Address - Street 1:625 W DICKEY RD
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-3129
Practice Address - Country:US
Practice Address - Phone:972-262-4391
Practice Address - Fax:972-264-6135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4925TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112248401Medicaid
TX00619UMedicare PIN
TX3905380001Medicare NSC