Healthcare Provider Details

I. General information

NPI: 1124697818
Provider Name (Legal Business Name): MICHELLE CHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 09/30/2021
Certification Date: 09/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 E CALAVERAS BLVD
MILPITAS CA
95035-5543
US

IV. Provider business mailing address

1751 APRILSONG CT
SAN JOSE CA
95131-2721
US

V. Phone/Fax

Practice location:
  • Phone: 408-263-2040
  • Fax:
Mailing address:
  • Phone: 408-828-7814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: