Provider Demographics
NPI:1679520365
Name:FAN, QING IVY (MD)
Entity Type:Individual
Prefix:
First Name:QING
Middle Name:IVY
Last Name:FAN
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 1:6817 SOUTHPOINT PKWY
Mailing Address - Street 2:#503
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6282
Mailing Address - Country:US
Mailing Address - Phone:904-296-9777
Mailing Address - Fax:904-296-9977
Practice Address - Street 1:6817 SOUTHPOINT PKWY
Practice Address - Street 2:#503
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6282
Practice Address - Country:US
Practice Address - Phone:904-296-9777
Practice Address - Fax:904-296-9977
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000040237207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL404037Medicaid
TN3336593Medicaid
FL404037Medicaid
FLAM076ZMedicare PIN
TN3336593Medicare ID - Type Unspecified