Provider Demographics
NPI:1407869993
Name:CHAN, PAUL K (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:K
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:PO BOX 541118
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-7118
Mailing Address - Country:US
Mailing Address - Phone:209-446-0321
Mailing Address - Fax:
Practice Address - Street 1:13347 SANFORD AVE APT 5B
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5813
Practice Address - Country:US
Practice Address - Phone:209-446-0321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY158093207Q00000X, 208D00000X
HIMD-10194208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice