Provider Demographics
NPI:1124556808
Name:CHAN, JOSHUA ISAO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSHUA
Middle Name:ISAO
Last Name:CHAN
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 1:120 MINEOLA BLVD STE 460
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-4067
Mailing Address - Country:US
Mailing Address - Phone:516-663-9400
Mailing Address - Fax:
Practice Address - Street 1:120 MINEOLA BLVD STE 460
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-4067
Practice Address - Country:US
Practice Address - Phone:516-663-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-25
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3057212080P0207X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-OncologyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program