Provider Demographics
NPI:1932330750
Name:CHAN, ALISHIA (OD)
Entity Type:Individual
Prefix:
First Name:ALISHIA
Middle Name:
Last Name:CHAN
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 1:3417 BROADWAY ST STE J3
Mailing Address - Street 2:
Mailing Address - City:AMERICAN CYN
Mailing Address - State:CA
Mailing Address - Zip Code:94503-1262
Mailing Address - Country:US
Mailing Address - Phone:707-553-6020
Mailing Address - Fax:707-643-2024
Practice Address - Street 1:3417 BROADWAY ST STE J3
Practice Address - Street 2:
Practice Address - City:AMERICAN CYN
Practice Address - State:CA
Practice Address - Zip Code:94503-1262
Practice Address - Country:US
Practice Address - Phone:707-553-6020
Practice Address - Fax:707-643-2024
Is Sole Proprietor?:No
Enumeration Date:2009-07-28
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT13810152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346255064OtherTAXID OF ANOTHER PRACTICE