Provider Demographics
NPI:1508286915
Name:GAN, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 S AUGUSTA CT
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-2013
Mailing Address - Country:US
Mailing Address - Phone:714-684-4487
Mailing Address - Fax:
Practice Address - Street 1:501 S IDAHO ST
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-6047
Practice Address - Country:US
Practice Address - Phone:562-690-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA149518207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program