Provider Demographics
NPI:1306986492
Name:CHANTADULY, WILLIAM V (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:V
Last Name:CHANTADULY
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 1:1463 HAIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-2910
Mailing Address - Country:US
Mailing Address - Phone:415-626-8686
Mailing Address - Fax:415-626-8799
Practice Address - Street 1:1463 HAIGHT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-2910
Practice Address - Country:US
Practice Address - Phone:415-626-8686
Practice Address - Fax:415-626-8799
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA11112T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0111120Medicaid
CAB83911Medicare UPIN