Provider Demographics
NPI:1457377210
Name:CHAN, CONNIE WINNIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:WINNIE
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2921 ERIE BLVD E
Mailing Address - Street 2:EMPIRE VISION CENTER, INC
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224-1430
Mailing Address - Country:US
Mailing Address - Phone:315-446-3145
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:139 ENDICOTT ST
Practice Address - Street 2:ENDICOTT PLAZA, MASS OPTOMETRIC ASSOCIATES, P. C.
Practice Address - City:DANVERS
Practice Address - State:MA
Practice Address - Zip Code:01923-4803
Practice Address - Country:US
Practice Address - Phone:978-777-4700
Practice Address - Fax:978-750-0862
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4531152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0703494Medicaid
MAW16427OtherBLUE CROSS BLUE SHIELD
MA0703494Medicaid
MAW16427OtherBLUE CROSS BLUE SHIELD