Provider Demographics
NPI:1962471664
Name:WAN, LAWRENCE K (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:K
Last Name:WAN
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 1:338 E HAMILTON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-0207
Mailing Address - Country:US
Mailing Address - Phone:408-866-2020
Mailing Address - Fax:408-370-3937
Practice Address - Street 1:338 E HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-0207
Practice Address - Country:US
Practice Address - Phone:408-866-2020
Practice Address - Fax:408-370-3937
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA07675 TPA152W00000X, 152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU38008Medicare UPIN
CASD0076751Medicare PIN