Provider Demographics
NPI:1922216373
Name:CHAN, GARRY D (OD)
Entity Type:Individual
Prefix:DR
First Name:GARRY
Middle Name:D
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 1:541 W VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3730
Mailing Address - Country:US
Mailing Address - Phone:626-289-8868
Mailing Address - Fax:626-289-9338
Practice Address - Street 1:541 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3730
Practice Address - Country:US
Practice Address - Phone:626-289-8868
Practice Address - Fax:626-289-9338
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10265T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD001400Medicaid
CAU63408Medicare UPIN
CAGSD001400Medicaid