Provider Demographics
NPI:1568408607
Name:PAN, DEBORAH (MD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:
Last Name:PAN
Suffix:
Gender:F
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 1:1 AUDUBON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6433
Mailing Address - Country:US
Mailing Address - Phone:203-562-7662
Mailing Address - Fax:203-562-7663
Practice Address - Street 1:1 AUDUBON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6433
Practice Address - Country:US
Practice Address - Phone:203-562-7662
Practice Address - Fax:203-562-7663
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT041129208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001411298Medicaid
CT001411298Medicaid
CT240000197Medicare PIN