Provider Demographics
NPI:1649347980
Name:CHAN, MATTHEW KIRK (OD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KIRK
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 1:4669 CLAYTON RD STE C
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-2964
Mailing Address - Country:US
Mailing Address - Phone:925-825-3900
Mailing Address - Fax:925-676-1771
Practice Address - Street 1:4669 CLAYTON RD STE C
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94521-2964
Practice Address - Country:US
Practice Address - Phone:925-825-3900
Practice Address - Fax:925-676-1771
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6180T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0061800Medicaid
T10255Medicare UPIN
CASD0061800Medicaid