Provider Demographics
NPI:1467463851
Name:PAN, EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:
Last Name:PAN
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 1:153 STEVENS AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550
Mailing Address - Country:US
Mailing Address - Phone:914-668-5585
Mailing Address - Fax:914-668-5603
Practice Address - Street 1:153 STEVENS AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550
Practice Address - Country:US
Practice Address - Phone:914-668-5585
Practice Address - Fax:914-668-5603
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197978207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01765475Medicaid
G55662Medicare UPIN
NY43G221Medicare ID - Type Unspecified