Provider Demographics
NPI:1164843090
Name:CHAN, ROBERT (DPT)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420A SAN MATEO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4417
Mailing Address - Country:US
Mailing Address - Phone:415-990-3106
Mailing Address - Fax:
Practice Address - Street 1:420A SAN MATEO AVE
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-4417
Practice Address - Country:US
Practice Address - Phone:415-990-3106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-19
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40896225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ06873ZMedicare PIN
CACA150499Medicare PIN