MEDICARE: EDMUND CHAN OD

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	TUV008725	NY

General Provider Information

NPI Number	:	1386128536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDMUND CHAN OD

Provider Business Mailing Address
First Line	:	33 MOTT ST
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10013-5021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6002 8TH AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11220-4338
Country	:	US
Telephone Number	:	718-439-2880
Fax Number	:

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

Provider Enumeration Date	:	09/23/2018
Last Update Date	:	07/02/2020

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