Provider Demographics
NPI:1053324574
Name:CHEN, EDEM FAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDEM
Middle Name:FAN
Last Name:CHEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 W KALEY ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2931
Mailing Address - Country:US
Mailing Address - Phone:407-423-2581
Mailing Address - Fax:407-849-6470
Practice Address - Street 1:20 W KALEY ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2931
Practice Address - Country:US
Practice Address - Phone:407-423-2581
Practice Address - Fax:407-849-6470
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME964262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004357500Medicaid
FL004357500Medicaid