Provider Demographics
NPI:1053314245
Name:CHAN, J. JACK (DO)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:JACK
Last Name:CHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 COLUMBUS RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1300
Mailing Address - Country:US
Mailing Address - Phone:740-594-2624
Mailing Address - Fax:740-594-7333
Practice Address - Street 1:86 COLUMBUS RD
Practice Address - Street 2:STE 203
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1331
Practice Address - Country:US
Practice Address - Phone:740-594-2624
Practice Address - Fax:740-594-7333
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2009-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34005890207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0956881Medicaid
OHE16668Medicare UPIN
OH0956881Medicaid