Provider Demographics
NPI:1164624334
Name:CHAN, WALLACE PETER (MD)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:PETER
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WIN
Other - Middle Name:MYINT
Other - Last Name:OO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2200 NORTHERN BLVD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548-1219
Mailing Address - Country:US
Mailing Address - Phone:516-325-7500
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHERN BLVD
Practice Address - Street 2:SUITE 111
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1219
Practice Address - Country:US
Practice Address - Phone:516-325-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244953207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology