Provider Demographics
NPI:1619002854
Name:CHAN, SUSANA (OD)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:
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 1:387 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02914-2618
Mailing Address - Country:US
Mailing Address - Phone:401-453-5800
Mailing Address - Fax:401-271-6867
Practice Address - Street 1:387 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:EAST PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02914-2618
Practice Address - Country:US
Practice Address - Phone:401-453-5800
Practice Address - Fax:401-271-6867
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00518152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
23-77354OtherUNITED HEALTHCARE
RI32425OtherNIEGHBORHOOD HEALTH PLAN
RI414188OtherBLUE CROSS
RI9082077Medicaid
RI0000032701OtherBRUE CROSS
RI9082077Medicaid