Healthcare Provider Details

I. General information

NPI: 1457377210
Provider Name (Legal Business Name): CONNIE WINNIE CHAN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 ENDICOTT ST ENDICOTT PLAZA, MASS OPTOMETRIC ASSOCIATES, P. C.
DANVERS MA
01923-4803
US

IV. Provider business mailing address

2921 ERIE BLVD E EMPIRE VISION CENTER, INC
SYRACUSE NY
13224-1430
US

V. Phone/Fax

Practice location:
  • Phone: 978-777-4700
  • Fax: 978-750-0862
Mailing address:
  • Phone: 315-446-3145
  • Fax: 315-445-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4531
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: