Provider Demographics
NPI:1730107327
Name:FAN, ANDY (MD)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 GREAT NECK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-4308
Mailing Address - Country:US
Mailing Address - Phone:516-482-6747
Mailing Address - Fax:516-482-4851
Practice Address - Street 1:488 GREAT NECK RD STE 300
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-4308
Practice Address - Country:US
Practice Address - Phone:516-482-6747
Practice Address - Fax:516-482-4851
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY239285207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology