Provider Demographics
NPI:1215063953
Name:CHAN, SELENA Y (OD)
Entity type:Individual
Prefix:DR
First Name:SELENA
Middle Name:Y
Last Name:CHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 IRVING ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2401
Mailing Address - Country:US
Mailing Address - Phone:415-661-8253
Mailing Address - Fax:415-661-2490
Practice Address - Street 1:619 IRVING ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94122-2401
Practice Address - Country:US
Practice Address - Phone:415-661-8253
Practice Address - Fax:415-661-2490
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11109T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGZ757ZMedicare PIN