Provider Demographics
NPI:1417918343
Name:CHAN, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 MARCUS DR
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4230
Mailing Address - Country:US
Mailing Address - Phone:631-391-7889
Mailing Address - Fax:631-454-4163
Practice Address - Street 1:8906 135TH ST
Practice Address - Street 2:SUITE 2T
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2821
Practice Address - Country:US
Practice Address - Phone:718-206-7110
Practice Address - Fax:718-206-7111
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY206686208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01755004Medicaid
G50295Medicare UPIN
NYG400024043Medicare PIN