Provider Demographics
NPI:1497794283
Name:CHAN, SUSANNA MINK (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNA
Middle Name:MINK
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:23600 TELO AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4035
Mailing Address - Country:US
Mailing Address - Phone:310-539-2055
Mailing Address - Fax:310-530-3999
Practice Address - Street 1:23600 TELO AVE
Practice Address - Street 2:260
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4035
Practice Address - Country:US
Practice Address - Phone:310-539-2055
Practice Address - Fax:310-530-3999
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA50571207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA39990Medicare UPIN
CAWA50571AMedicare UPIN