Provider Demographics
NPI:1154326783
Name:CHAN, PAUL H (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:H
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:PO BOX 1525
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1525
Mailing Address - Country:US
Mailing Address - Phone:334-678-1400
Mailing Address - Fax:334-678-1432
Practice Address - Street 1:1800 FAIRVIEW AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3058
Practice Address - Country:US
Practice Address - Phone:334-678-1400
Practice Address - Fax:334-678-1432
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL13615207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529913350Medicaid
ALDE5059OtherRRMC
AL529913350Medicaid
AL051512284Medicare Oscar/Certification
K710Medicare PIN