Provider Demographics
NPI:1912969221
Name:CHAN, ROGER STEPHEN (OD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:STEPHEN
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 1:7204 REGIONAL ST
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-2326
Mailing Address - Country:US
Mailing Address - Phone:925-803-1010
Mailing Address - Fax:925-803-1030
Practice Address - Street 1:7204 REGIONAL ST
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-2326
Practice Address - Country:US
Practice Address - Phone:925-803-1010
Practice Address - Fax:925-803-1030
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9659152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0096590Medicaid
CASD0096590Medicaid
CACA119579Medicare PIN