Provider Demographics
NPI:1477631265
Name:FAN, PELLY (MD)
Entity Type:Individual
Prefix:
First Name:PELLY
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:275 W MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5641
Mailing Address - Country:US
Mailing Address - Phone:510-752-1000
Mailing Address - Fax:
Practice Address - Street 1:275 W MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5641
Practice Address - Country:US
Practice Address - Phone:510-752-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61460208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A614600Medicaid
H36195Medicare UPIN
CA00A614600Medicaid