Provider Demographics
NPI:1629051529
Name:CHAN, CHIWAI E (DO)
Entity Type:Individual
Prefix:
First Name:CHIWAI
Middle Name:E
Last Name:CHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11160 WARNER AVE
Mailing Address - Street 2:417
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-8703
Mailing Address - Country:US
Mailing Address - Phone:714-424-9300
Mailing Address - Fax:714-424-9324
Practice Address - Street 1:11160 WARNER AVE
Practice Address - Street 2:417
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4008
Practice Address - Country:US
Practice Address - Phone:714-424-9300
Practice Address - Fax:714-424-9324
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ4242208VP0000X
CA20A8068208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1629051529Medicare PIN
AZ86080015085259C462OtherTRIWEST
I32848Medicare UPIN
AZ944406Medicaid