Provider Demographics
NPI:1790955367
Name:CHAN, TIMOTHY I (DPM)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:CHAN
Suffix:I
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 GOLF COURSE RD SE STE A
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1954
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2207 GOLF COURSE RD SE STE A
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1954
Practice Address - Country:US
Practice Address - Phone:575-521-0055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3400213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCZ549ZOtherMCR
FL6364940001OtherPTAN
FL1790955367OtherNPI
FLCZ549ZOtherMCR
FL6364940001Medicare NSC