MEDICARE: DR. WILLIAM V CHANTADULY 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	CA11112T	CA

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	:	1306986492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WILLIAM V CHANTADULY O.D.

Provider Business Mailing Address
First Line	:	1463 HAIGHT ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94117-2910
Country	:	US
Telephone Number	:	415-626-8686
Fax Number	:	415-626-8799

Provider Business Practice Location Address
First Line	:	1463 HAIGHT ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94117-2910
Country	:	US
Telephone Number	:	415-626-8686
Fax Number	:	415-626-8799

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

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	07/08/2007

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