Provider Demographics
NPI:1114966561
Name:FAN, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FAN
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 1:200 ORCHARD ST
Mailing Address - Street 2:303
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5363
Mailing Address - Country:US
Mailing Address - Phone:203-867-5600
Mailing Address - Fax:
Practice Address - Street 1:200 ORCHARD ST
Practice Address - Street 2:303
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5363
Practice Address - Country:US
Practice Address - Phone:203-867-5600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038797207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTH40661Medicare UPIN