Provider Demographics
NPI:1477657922
Name:CHAN, PEDRO Y (RPH, DO)
Entity Type:Individual
Prefix:DR
First Name:PEDRO
Middle Name:Y
Last Name:CHAN
Suffix:
Gender:M
Credentials:RPH, DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LAKE HAYES RD
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-9097
Mailing Address - Country:US
Mailing Address - Phone:407-365-9010
Mailing Address - Fax:407-365-9032
Practice Address - Street 1:101 LAKE HAYES RD
Practice Address - Street 2:SUITE # 101
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-9097
Practice Address - Country:US
Practice Address - Phone:407-365-9010
Practice Address - Fax:407-365-9032
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS5060207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046866500Medicaid
FL82924ZMedicare PIN
FLD60767Medicare UPIN
FL82924Medicare ID - Type Unspecified