Provider Demographics
NPI:1356309603
Name:CHAN, ENOCH CHUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:ENOCH
Middle Name:CHUNG
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 1:1461 LAKELAND AVE UNIT 14
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-2174
Mailing Address - Country:US
Mailing Address - Phone:631-218-8800
Mailing Address - Fax:631-218-8801
Practice Address - Street 1:1461 LAKELAND AVE UNIT 14
Practice Address - Street 2:
Practice Address - City:BOHEMIA
Practice Address - State:NY
Practice Address - Zip Code:11716-2174
Practice Address - Country:US
Practice Address - Phone:631-218-8800
Practice Address - Fax:631-218-8801
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1356309603OtherUNITED HEALTHCARE
NY01837470Medicaid
NYG62711Medicare UPIN
NY068AM1Medicare ID - Type Unspecified
NY1356309603OtherUNITED HEALTHCARE