Provider Demographics
NPI:1740664705
Name:FAN, JANICE (OD)
Entity type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:FAN
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 1:3925 S 76TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53220-2320
Mailing Address - Country:US
Mailing Address - Phone:504-495-3887
Mailing Address - Fax:
Practice Address - Street 1:3925 S 76TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53220-2320
Practice Address - Country:US
Practice Address - Phone:414-543-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-18
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3391-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist