Provider Demographics
NPI:1679541569
Name:CHAN, ROLYCITO A (MD)
Entity Type:Individual
Prefix:
First Name:ROLYCITO
Middle Name:A
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 ENGLE ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-1823
Mailing Address - Country:US
Mailing Address - Phone:201-871-6073
Mailing Address - Fax:201-655-6159
Practice Address - Street 1:350 ENGLE ST
Practice Address - Street 2:2ND FLOOR, ANESTHESIA DEPT
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3322
Practice Address - Fax:201-894-0585
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03602400207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01060728Medicaid
NJ2500001Medicaid
NJD18651Medicare UPIN
NY01060728Medicaid