Provider Demographics
NPI:1609847979
Name:PAN, TEDDY D (MD)
Entity Type:Individual
Prefix:DR
First Name:TEDDY
Middle Name:D
Last Name:PAN
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 1:105 EVERETT RD
Mailing Address - Street 2:
Mailing Address - City:COLONIE
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1407
Mailing Address - Country:US
Mailing Address - Phone:518-694-0999
Mailing Address - Fax:
Practice Address - Street 1:105 EVERETT RD
Practice Address - Street 2:
Practice Address - City:COLONIE
Practice Address - State:NY
Practice Address - Zip Code:12205-1407
Practice Address - Country:US
Practice Address - Phone:518-694-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239724-1207ND0900X, 207ND0900X
RIMD10316207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H31751Medicare UPIN
NYRB2498Medicare PIN