Provider Demographics
NPI:1629191663
Name:FAN, ERIC C (DO)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:C
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
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Mailing Address - Street 1:129 SWEETBRIAR LAKES DR
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31757-0001
Mailing Address - Country:US
Mailing Address - Phone:850-766-6566
Mailing Address - Fax:
Practice Address - Street 1:1102 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5739
Practice Address - Country:US
Practice Address - Phone:229-225-4335
Practice Address - Fax:229-225-4374
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA496152084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
26BDHLHMedicare PIN
F30101Medicare UPIN