Provider Demographics
NPI:1558369397
Name:CHAN, ALFONSO YU (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:YU
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 1:105 WHEATLEY RD
Mailing Address - Street 2:
Mailing Address - City:OLD WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11568-1210
Mailing Address - Country:US
Mailing Address - Phone:516-625-9240
Mailing Address - Fax:
Practice Address - Street 1:6200 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1409
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2012-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY108148207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01696753Medicaid
NYC12119Medicare UPIN
NY331841Medicare ID - Type Unspecified