Healthcare Provider Details

I. General information

NPI: 1942294442
Provider Name (Legal Business Name): MICHELLE CHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3878
US

IV. Provider business mailing address

3241 S MICHIGAN AVE
CHICAGO IL
60616-3878
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-6200
  • Fax: 312-949-7660
Mailing address:
  • Phone: 312-949-7000
  • Fax: 312-949-7642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: