Provider Demographics
NPI:1255466017
Name:FAN, FOUN-CHUNG (MD)
Entity Type:Individual
Prefix:
First Name:FOUN-CHUNG
Middle Name:
Last Name:FAN
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 1:3100 SPRING FOREST RD
Mailing Address - Street 2:STE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0706
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:25B VREELAND RD
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-1900
Practice Address - Country:US
Practice Address - Phone:973-660-9334
Practice Address - Fax:973-660-9732
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA03990800207L00000X
NJ25MA03990800207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3092801Medicaid
NJ003053CNKMedicare PIN
NJC52437Medicare UPIN