Provider Demographics
NPI:1992194203
Name:CHAN, TIFFANY K (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:K
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 1:825 LOS POSITOS DR
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-4514
Mailing Address - Country:US
Mailing Address - Phone:415-810-0715
Mailing Address - Fax:
Practice Address - Street 1:1635 DIVISADERO ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3036
Practice Address - Country:US
Practice Address - Phone:415-833-5665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-10
Last Update Date:2015-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15106152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist