Provider Demographics
NPI:1528019924
Name:CHAN, CARLYLE H (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLYLE
Middle Name:H
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 1:1155 N MAYFAIR RD FL 3
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3464
Mailing Address - Country:US
Mailing Address - Phone:414-955-8900
Mailing Address - Fax:414-955-6285
Practice Address - Street 1:1155 N MAYFAIR RD FL 3
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3464
Practice Address - Country:US
Practice Address - Phone:414-955-8900
Practice Address - Fax:414-955-6285
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI229942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528019924Medicaid
002000112GOtherHUMANA
WI30353500Medicaid
002000112GOtherHUMANA
WI1528019924Medicaid