Provider Demographics
NPI:1447770136
Name:CHAN, JACK FONG JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:FONG
Last Name:CHAN
Suffix:JR
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 1:12212 SCULLY AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-3339
Mailing Address - Country:US
Mailing Address - Phone:408-921-3303
Mailing Address - Fax:
Practice Address - Street 1:12212 SCULLY AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-3339
Practice Address - Country:US
Practice Address - Phone:408-921-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21437208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty