Provider Demographics
NPI:1619116597
Name:FAN, DAPENG (MD)
Entity Type:Individual
Prefix:
First Name:DAPENG
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 BEACH 105TH ST
Mailing Address - Street 2:APT. 1X
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2695
Mailing Address - Country:US
Mailing Address - Phone:201-804-2800
Mailing Address - Fax:201-804-8883
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-1664
Practice Address - Country:US
Practice Address - Phone:718-818-2843
Practice Address - Fax:718-818-4709
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY253526207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY253526OtherTHE UNIVERSITY OF THE STATE OF NEW YORK -EDUCATION DEPARTMENT
PAMD436206OtherLICENSE