Provider Demographics
NPI:1003813247
Name:PAN, ELLEN (MD)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:
Last Name:PAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8301 BAY PARKWAY
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214
Mailing Address - Country:US
Mailing Address - Phone:718-236-7772
Mailing Address - Fax:718-256-4178
Practice Address - Street 1:8301 BAY PARKWAY
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214
Practice Address - Country:US
Practice Address - Phone:718-236-7772
Practice Address - Fax:718-256-4178
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136911-1207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05589708-9Medicaid
48A701Medicare PIN