Provider Demographics
NPI:1578549986
Name:CHAN, PETER S (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:S
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:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-0116
Mailing Address - Country:US
Mailing Address - Phone:800-624-0792
Mailing Address - Fax:201-943-8733
Practice Address - Street 1:1590 ROUTE 206 NORTH BOUND
Practice Address - Street 2:
Practice Address - City:BEDMINSTER
Practice Address - State:NJ
Practice Address - Zip Code:07921
Practice Address - Country:US
Practice Address - Phone:908-253-0800
Practice Address - Fax:908-253-0838
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07248800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ080381Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER