Provider Demographics
NPI:1033108923
Name:CANCER CARE ASSOCIATES MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CANCER CARE ASSOCIATES MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-750-3300
Mailing Address - Street 1:514 N PROSPECT AVE
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-3040
Mailing Address - Country:US
Mailing Address - Phone:310-750-3300
Mailing Address - Fax:310-750-3381
Practice Address - Street 1:514 N PROSPECT AVE
Practice Address - Street 2:4TH FLOOR
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-3040
Practice Address - Country:US
Practice Address - Phone:310-750-3300
Practice Address - Fax:310-750-3381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP17913207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ28793ZOtherBLUE SHIELD
W499AMedicare ID - Type Unspecified
ZZZ28793ZOtherBLUE SHIELD