Provider Demographics
NPI:1124225578
Name:FAN, ZHAIJUN (DO)
Entity Type:Individual
Prefix:
First Name:ZHAIJUN
Middle Name:
Last Name:FAN
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 1:710 N. NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:1815 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2845
Practice Address - Country:US
Practice Address - Phone:574-647-1750
Practice Address - Fax:574-647-1748
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003570A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200977390Medicaid
INM400018066OtherMEDICARE PTAN
INM400018009OtherMEDICARE PTAN