Provider Demographics
NPI:1609859875
Name:CHAN, PEGGY (MD)
Entity Type:Individual
Prefix:DR
First Name:PEGGY
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1666
Mailing Address - Country:US
Mailing Address - Phone:718-876-2000
Mailing Address - Fax:718-876-2006
Practice Address - Street 1:360 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1666
Practice Address - Country:US
Practice Address - Phone:718-876-2000
Practice Address - Fax:718-876-2006
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233455207U00000X
IL036168022207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02685490Medicaid
NY0560ANMedicare ID - Type UnspecifiedMEDICARE GHI
NY02685490Medicaid
NY9N2511Medicare ID - Type UnspecifiedMEDICARE EMPIRE