Provider Demographics
NPI:1871658740
Name:FAN, JUDY S (OD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:S
Last Name:FAN
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 1:10603 MULHALL ST
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-1233
Mailing Address - Country:US
Mailing Address - Phone:619-218-2335
Mailing Address - Fax:818-348-7724
Practice Address - Street 1:400 S BALDWIN AVE
Practice Address - Street 2:SANTA ANITA FASHION PARK
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-1900
Practice Address - Country:US
Practice Address - Phone:626-445-2446
Practice Address - Fax:626-445-1536
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12571T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV01481Medicare UPIN
CAWOP125171Medicare ID - Type Unspecified