Provider Demographics
NPI:1851824528
Name:FAN, HEINRICH DAVID (MD)
Entity Type:Individual
Prefix:
First Name:HEINRICH
Middle Name:DAVID
Last Name:FAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6264 E STAR VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-9647
Mailing Address - Country:US
Mailing Address - Phone:480-754-9231
Mailing Address - Fax:
Practice Address - Street 1:2375 E PRATER WAY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89434-9641
Practice Address - Country:US
Practice Address - Phone:775-331-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2020-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR76036207P00000X
NV19752207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty