Provider Demographics
NPI:1386672053
Name:CHAN, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
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 1:506 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-1802
Mailing Address - Country:US
Mailing Address - Phone:212-939-4902
Mailing Address - Fax:212-939-4836
Practice Address - Street 1:506 LENOX AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-4902
Practice Address - Fax:212-939-4836
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163256-12085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131108Medicaid
NYW35021OtherMEDICARE GROUP #
NY02186203OtherMEDICAID GROUP #
NY17F251Medicare UPIN
NY01131108Medicaid