Provider Demographics
NPI:1588665657
Name:FAN, BUNCHEN (MD)
Entity Type:Individual
Prefix:
First Name:BUNCHEN
Middle Name:
Last Name:FAN
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 1:4124 ROSEMEAD BLVD
Mailing Address - Street 2:#A
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-4400
Mailing Address - Country:US
Mailing Address - Phone:626-285-2477
Mailing Address - Fax:626-285-1003
Practice Address - Street 1:4124 ROSEMEAD BLVD
Practice Address - Street 2:#A
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-4400
Practice Address - Country:US
Practice Address - Phone:626-285-2477
Practice Address - Fax:626-285-1003
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43151174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA431511Medicaid