Provider Demographics
NPI:1730114711
Name:GAN, MICHELLE A (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:A
Last Name:GAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9975 CARMEL MOUNTAIN RD
Mailing Address - Street 2:G6
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2800
Mailing Address - Country:US
Mailing Address - Phone:858-780-9889
Mailing Address - Fax:858-780-9876
Practice Address - Street 1:9975 CARMEL MOUNTAIN RD
Practice Address - Street 2:G6
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2800
Practice Address - Country:US
Practice Address - Phone:858-780-9889
Practice Address - Fax:858-780-9876
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAOPT 12577 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0125770Medicaid
CAV01299Medicare UPIN
BU874ZMedicare PIN