Provider Demographics
NPI:1508859398
Name:CHAN, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:CHAN
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:PO BOX 28128
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-8128
Mailing Address - Country:US
Mailing Address - Phone:559-436-0871
Mailing Address - Fax:559-436-5221
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4405
Practice Address - Country:US
Practice Address - Phone:209-576-3514
Practice Address - Fax:209-342-3492
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2009-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38491207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G384911Medicaid
CAG45267Medicare UPIN
CA00G384911Medicaid