Provider Demographics
NPI:1760473854
Name:CHAN JR., LAWRENCE (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:
Last Name:CHAN JR.
Suffix:
Gender:M
Credentials:OD
Other - Prefix:DR
Other - First Name:LAWRENCE
Other - Middle Name:
Other - Last Name:CHAN JR.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2524 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-3101
Mailing Address - Country:US
Mailing Address - Phone:503-761-2121
Mailing Address - Fax:503-761-2122
Practice Address - Street 1:2524 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-3101
Practice Address - Country:US
Practice Address - Phone:503-761-2121
Practice Address - Fax:503-761-2122
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR793152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist