MEDICARE: CHRISTINE W 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	OPT 12385 TPA	CA

General Provider Information

NPI Number	:	1770692436
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE W CHAN O.D.

Provider Business Mailing Address
First Line	:	1368 E WALNUT ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1528
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1368 E WALNUT ST
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91106-1528
Country	:	US
Telephone Number	:	626-796-3105
Fax Number	:	626-796-8816

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

Provider Enumeration Date	:	08/29/2006
Last Update Date	:	07/08/2007

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