Provider Demographics
NPI:1003254012
Name:CHAN, KATHERINE LILLIAN (MD)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LILLIAN
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:KATHERINE
Other - Middle Name:LILLIAN
Other - Last Name:STITELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:798 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6392
Mailing Address - Country:US
Mailing Address - Phone:407-359-8580
Mailing Address - Fax:
Practice Address - Street 1:798 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765
Practice Address - Country:US
Practice Address - Phone:407-359-8580
Practice Address - Fax:407-359-8364
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA076953207Q00000X
SC35648207Q00000X
FLME136423207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine