Provider Demographics
NPI:1437655644
Name:CHAN, JOHN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THOMAS
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 1:4200 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5902
Mailing Address - Country:US
Mailing Address - Phone:916-461-4769
Mailing Address - Fax:
Practice Address - Street 1:2372 MARITIME DR
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-3639
Practice Address - Country:US
Practice Address - Phone:408-885-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA164300208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation