Provider Demographics
NPI:1508928128
Name:FAN, ROGER (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:FAN
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:HEALTH SCIENCES CTR
Mailing Address - Street 2:T16-080
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-0001
Mailing Address - Country:US
Mailing Address - Phone:631-444-1226
Mailing Address - Fax:
Practice Address - Street 1:HEALTH SCIENCES CTR
Practice Address - Street 2:T16-080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-1226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT184514207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease