MEDICARE: WALLACE CHAN O.D.

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	046-008575	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053360735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WALLACE CHAN O.D.

Provider Business Mailing Address
First Line	:	2126A S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1514
Country	:	US
Telephone Number	:	312-949-1888
Fax Number	:	312-949-0288

Provider Business Practice Location Address
First Line	:	2126A S ARCHER AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-1514
Country	:	US
Telephone Number	:	312-949-1888
Fax Number	:	312-949-0288

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

Provider Enumeration Date	:	05/09/2006
Last Update Date	:	11/11/2008

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