Provider Demographics
NPI:1730142183
Name:CHAN, SAMUEL C (DO)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:C
Last Name:CHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:5787 S HAMPTON RD
Mailing Address - Street 2:SUITE 300, LB 134
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75232-2255
Mailing Address - Country:US
Mailing Address - Phone:214-330-3034
Mailing Address - Fax:214-330-3096
Practice Address - Street 1:5787 S HAMPTON RD
Practice Address - Street 2:SUITE 300, LB 134
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75232-2255
Practice Address - Country:US
Practice Address - Phone:214-330-3034
Practice Address - Fax:214-330-3096
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX134064804Medicaid
TX87840NMedicare PIN
E89798Medicare UPIN