Provider Demographics
NPI:1790185932
Name:CHAN, JOHN (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5581 ANSHAN ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-7719
Mailing Address - Country:US
Mailing Address - Phone:909-263-3465
Mailing Address - Fax:661-869-2708
Practice Address - Street 1:695 S GREEN VALLEY PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-0404
Practice Address - Country:US
Practice Address - Phone:909-263-3465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15099152W00000X
NV975152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist