Provider Demographics
NPI:1528033545
Name:CHAN, KWOK ON (MD)
Entity Type:Individual
Prefix:DR
First Name:KWOK
Middle Name:ON
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 FAIRWAY XING
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1450
Mailing Address - Country:US
Mailing Address - Phone:860-647-1912
Mailing Address - Fax:860-647-1912
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:860-647-1912
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031901207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001319012Medicaid
F28791Medicare UPIN
CT001319012Medicaid