Provider Demographics
NPI:1972732352
Name:CHAN, JOHNNY (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
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 1:4010 172ND ST
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98223
Mailing Address - Country:US
Mailing Address - Phone:360-386-4612
Mailing Address - Fax:360-659-7399
Practice Address - Street 1:4010 172ND ST
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223
Practice Address - Country:US
Practice Address - Phone:360-386-4612
Practice Address - Fax:360-659-7399
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60096337152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist