MEDICARE: DR. KEITH MICHAEL WAN O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	10924T	CA

General Provider Information

NPI Number	:	1235181165
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH MICHAEL WAN O.D.

Provider Business Mailing Address
First Line	:	10549 SCRIPPS POWAY PKWY
Second Line	:	STE G
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-3963
Country	:	US
Telephone Number	:	858-530-2800
Fax Number	:	858-530-2889

Provider Business Practice Location Address
First Line	:	10549 SCRIPPS POWAY PKWY
Second Line	:	STE G
City	:	SAN DIEGO
State	:	CA
Zip	:	92131-3963
Country	:	US
Telephone Number	:	858-530-2800
Fax Number	:	858-530-2889

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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