Provider Demographics
NPI:1083680730
Name:CHAN, KEVIN KIEN MAN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:KIEN MAN
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KIEN MAN
Other - Middle Name:
Other - Last Name:TRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:751 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2604
Mailing Address - Country:US
Mailing Address - Phone:408-885-5000
Mailing Address - Fax:
Practice Address - Street 1:751 S BASCOM AVE
Practice Address - Street 2:ANESTHESIOLOGY DEPT
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2604
Practice Address - Country:US
Practice Address - Phone:408-885-5745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55542207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A555420Medicaid
CAG36689Medicare UPIN
CA00A555420Medicare PIN