Provider Demographics
NPI:1053360735
Name:CHAN, WALLACE (OD)
Entity type:Individual
Prefix:
First Name:WALLACE
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2126A S ARCHER AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-1514
Mailing Address - Country:US
Mailing Address - Phone:312-949-1888
Mailing Address - Fax:312-949-0288
Practice Address - Street 1:2126A S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-1514
Practice Address - Country:US
Practice Address - Phone:312-949-1888
Practice Address - Fax:312-949-0288
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-008575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046008575Medicaid
ILK18079Medicare PIN