Provider Demographics
NPI:1801971981
Name:CHAN, DAVID (OD)
Entity type:Individual
Prefix:DR
First Name:DAVID
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 1:4240 ROCKLIN RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2862
Mailing Address - Country:US
Mailing Address - Phone:916-624-0508
Mailing Address - Fax:916-624-4727
Practice Address - Street 1:4240 ROCKLIN RD
Practice Address - Street 2:SUITE #3
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2862
Practice Address - Country:US
Practice Address - Phone:916-624-0508
Practice Address - Fax:916-624-4727
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7755T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0868590001OtherDMEPOS SUPPLIER NUMBER
CASD0077550Medicaid
CASD0077550Medicare ID - Type Unspecified
CASD0077550Medicaid