Provider Demographics
NPI:1639105745
Name:CHAN, CONNIE (DO)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 ROLLING GREEN DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-1525
Mailing Address - Country:US
Mailing Address - Phone:805-928-5331
Mailing Address - Fax:805-928-5331
Practice Address - Street 1:525 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-1202
Practice Address - Country:US
Practice Address - Phone:626-307-2129
Practice Address - Fax:626-307-2056
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2008-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6654207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX66540Medicaid
CAW20A6654FMedicare PIN
CAH20A6654BMedicare PIN
CAH20A6654AMedicare PIN
CAH20336Medicare UPIN