Provider Demographics
NPI:1770843112
Name:CHAN, JEFFREY DULAY
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DULAY
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 S IMPERIAL AVE
Mailing Address - Street 2:
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92243-4200
Mailing Address - Country:US
Mailing Address - Phone:760-352-3108
Mailing Address - Fax:760-352-3234
Practice Address - Street 1:1605 SCOTT AVE STE 400
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-1790
Practice Address - Country:US
Practice Address - Phone:760-352-3108
Practice Address - Fax:760-352-3234
Is Sole Proprietor?:No
Enumeration Date:2012-05-18
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA698955163WH0200X
CA95018570363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner