Provider Demographics
NPI:1942294442
Name:CHAN, MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:CHAN
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 1:3241 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-3878
Mailing Address - Country:US
Mailing Address - Phone:312-949-7000
Mailing Address - Fax:312-949-7642
Practice Address - Street 1:3241 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-3878
Practice Address - Country:US
Practice Address - Phone:312-225-6200
Practice Address - Fax:312-949-7660
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U96831Medicare UPIN
ILK00993Medicare ID - Type Unspecified