Basic Information
| Provider Information | |||||||||
| NPI: | 1912991415 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FAN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 W DICKEY RD | ||||||||
| Address2: | |||||||||
| City: | GRAND PRAIRIE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750513129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9722624391 | ||||||||
| FaxNumber: | 9722646135 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 10/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/25/2006 | ||||||||
| NPIReactivationDate: | 03/30/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 4925TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 157827001 | 05 | TX | MEDICAID |