Provider Demographics
NPI:1578761656
Name:CHAN, ELLIE EIEI (MD)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:EIEI
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:FANNY
Other - Middle Name:
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2335 E KASHIAN LN
Practice Address - Street 2:SUITE 301
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2230
Practice Address - Country:US
Practice Address - Phone:559-256-9680
Practice Address - Fax:559-256-9681
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110958207R00000X, 207RH0000X, 207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVLL1774OtherNV MEDICAL LIC