Provider Demographics
NPI:1518069111
Name:PEDRO Y. CHAN, R.PH., DO, PA
Entity Type:Organization
Organization Name:PEDRO Y. CHAN, R.PH., DO, PA
Other - Org Name:OVIEDO FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PEDRO
Authorized Official - Middle Name:Y
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:RPH, DO
Authorized Official - Phone:407-365-9010
Mailing Address - Street 1:101 LAKE HAYES RD
Mailing Address - Street 2:STE 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:
Practice Address - Street 1:101 LAKE HAYES RD
Practice Address - Street 2:STE 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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL046866500Medicaid
FLD60767Medicare UPIN
FL046866500Medicaid