Provider Demographics
NPI:1194205237
Name:CHAN, BRIAN PAK HO (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAK HO
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 1:330 BROOKLINE AVENUE
Mailing Address - Street 2:STONEMAN 458
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215
Mailing Address - Country:US
Mailing Address - Phone:617-667-2136
Mailing Address - Fax:617-667-1728
Practice Address - Street 1:330 BROOKLINE AVENUE
Practice Address - Street 2:STONEMAN 458
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-667-2136
Practice Address - Fax:617-667-1728
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2019-04-10
Deactivation Date:2019-03-25
Deactivation Code:
Reactivation Date:2019-04-01
Provider Licenses
StateLicense IDTaxonomies
MA277470390200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
100258OtherCPSO