Basic Information
| Provider Information | |||||||||
| NPI: | 1710021274 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLIAM FAN, OD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 W DICKEY RD | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750513129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722624391 | ||||||||
| FaxNumber: | 9722646135 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 W DICKEY RD | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750513129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722624391 | ||||||||
| FaxNumber: | 9722646135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2007 | ||||||||
| LastUpdateDate: | 03/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | FAN | ||||||||
| AuthorizedOfficialFirstName: | WILLLIAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9722624391 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | O.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4925TG | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 112248401 | 05 | TX | MEDICAID |