Provider Demographics
NPI:1275604480
Name:FAN, ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
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 1:8110 AIRPORT BLVD
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3119
Mailing Address - Country:US
Mailing Address - Phone:310-674-0144
Mailing Address - Fax:
Practice Address - Street 1:8110 AIRPORT BLVD
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3119
Practice Address - Country:US
Practice Address - Phone:310-674-0144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI39707Medicare UPIN