Provider Demographics
NPI:1538264601
Name:GERALD D. CHAN, O.D. & LISA E. MOON, O.D.
Entity type:Organization
Organization Name:GERALD D. CHAN, O.D. & LISA E. MOON, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:530-273-3190
Mailing Address - Street 1:360 SIERRA COLLEGE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5088
Mailing Address - Country:US
Mailing Address - Phone:530-273-3190
Mailing Address - Fax:530-273-5541
Practice Address - Street 1:360 SIERRA COLLEGE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5088
Practice Address - Country:US
Practice Address - Phone:530-273-3190
Practice Address - Fax:530-273-5541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5832 T & 6088 T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP5473OtherRR MEDICARE
CAYYY49206YMedicaid
CACP5473Medicare PIN
CP5473OtherRR MEDICARE
CAYYY49206YMedicaid