Provider Demographics
NPI:1801206750
Name:FAN, KENNETH (DO)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:FAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 ADMIRALS WALK
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-4333
Mailing Address - Country:US
Mailing Address - Phone:626-841-8082
Mailing Address - Fax:
Practice Address - Street 1:219 BRYANT ST
Practice Address - Street 2:UNIVERSITY AT BUFFALO DEPARTMENT OF OB/GYN
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14222
Practice Address - Country:US
Practice Address - Phone:716-878-7750
Practice Address - Fax:716-888-3833
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY294548207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program