Healthcare Provider Details

I. General information

NPI: 1407508385
Provider Name (Legal Business Name): KWOK FUNG CHAN OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RICKY KF CHAN OD

II. Dates (important events)

Enumeration Date: 01/22/2022
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

523 TELEGRAPH CANYON RD
CHULA VISTA CA
91910-6436
US

IV. Provider business mailing address

2650 JAMACHA RD STE 155
EL CAJON CA
92019-4319
US

V. Phone/Fax

Practice location:
  • Phone: 619-482-2020
  • Fax: 619-482-2671
Mailing address:
  • Phone: 619-670-6296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35087
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: