Provider Demographics
NPI:1396200176
Name:SUSANNA CHAN D.P.M., INC
Entity Type:Organization
Organization Name:SUSANNA CHAN D.P.M., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:626-759-7565
Mailing Address - Street 1:113 E COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8283 GROVE AVE STE 207B
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3141
Practice Address - Country:US
Practice Address - Phone:909-500-3007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty