Provider Demographics
NPI:1609830348
Name:CHAN, SHIRLEY M
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:M
Last Name:CHAN
Suffix:
Gender:F
Credentials:
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 80305
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8305
Mailing Address - Country:US
Mailing Address - Phone:818-243-8431
Mailing Address - Fax:818-247-9239
Practice Address - Street 1:1505 WILSON TERRACE
Practice Address - Street 2:SUITE 350
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4072
Practice Address - Country:US
Practice Address - Phone:818-243-8431
Practice Address - Fax:818-247-9239
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG58168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G581680Medicaid
CAE73295Medicare UPIN
CA00G581680Medicaid