Provider Demographics
NPI:1083058432
Name:IAN CHAN MD PC
Entity Type:Organization
Organization Name:IAN CHAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-213-1668
Mailing Address - Street 1:139 CENTRE ST PH 113
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-4559
Mailing Address - Country:US
Mailing Address - Phone:631-213-1668
Mailing Address - Fax:
Practice Address - Street 1:139 CENTRE ST PH 113
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013
Practice Address - Country:US
Practice Address - Phone:631-213-1668
Practice Address - Fax:718-509-6993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-28
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249201261QS0132X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0132XAmbulatory Health Care FacilitiesClinic/CenterOphthalmologic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03580976Medicaid
NY03580976Medicaid