Provider Demographics
NPI:1184019770
Name:CHAN, CAROLYN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANNE
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3131 HARVEY AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3006
Mailing Address - Country:US
Mailing Address - Phone:513-585-8227
Mailing Address - Fax:
Practice Address - Street 1:3131 HARVEY AVE STE 104
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3006
Practice Address - Country:US
Practice Address - Phone:513-585-8227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT64945207R00000X
OH35.132746207R00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056168Medicaid
CT008068298Medicaid
CT004217099Medicaid
CT008039745Medicaid
CT008056033Medicaid
CT008095233Medicaid