Provider Demographics
NPI:1700825312
Name:FAN, TERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
Middle Name:
Last Name:FAN
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 1:5341 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4078
Mailing Address - Country:US
Mailing Address - Phone:714-477-8490
Mailing Address - Fax:714-477-8491
Practice Address - Street 1:5341 WARNER AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-4078
Practice Address - Country:US
Practice Address - Phone:714-477-8490
Practice Address - Fax:714-477-8491
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A903000Medicaid
CAWA90300AMedicare PIN
CA00A903000Medicaid