Provider Demographics
NPI:1912991415
Name:FAN, WILLIAM (OD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:
Last Name:FAN
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 1:708 E 15TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5774
Mailing Address - Country:US
Mailing Address - Phone:972-509-8555
Mailing Address - Fax:972-509-8556
Practice Address - Street 1:708 E 15TH ST STE A
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5774
Practice Address - Country:US
Practice Address - Phone:972-509-8555
Practice Address - Fax:972-509-8556
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2023-11-15
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-03-30
Provider Licenses
StateLicense IDTaxonomies
TX4925TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157827001Medicaid
TX8A2810Medicare PIN
U49600Medicare UPIN
TX3905380001Medicare NSC