Provider Demographics
NPI:1033457270
Name:CHIN, CHANA IVY CHANTAWANSRI (MD)
Entity Type:Individual
Prefix:
First Name:CHANA
Middle Name:IVY CHANTAWANSRI
Last Name:CHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 COLDWATER CANYON
Mailing Address - Street 2:204
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604
Mailing Address - Country:US
Mailing Address - Phone:818-383-8065
Mailing Address - Fax:
Practice Address - Street 1:4650 SUNSET BOULEVARD #83
Practice Address - Street 2:150
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-361-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-23
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112215208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics