Provider Demographics
NPI:1194832592
Name:CHAN, VINCENT T (MD)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:T
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1801 NW MARKET ST
Practice Address - Street 2:SUITE 411
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-3987
Practice Address - Country:US
Practice Address - Phone:206-781-6072
Practice Address - Fax:206-781-6073
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML20007367207Y00000X
MA235115207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA000601402Medicare PIN
MA000601401Medicare PIN