Provider Demographics
NPI:1861448961
Name:CHAN, GINIE (MD)
Entity Type:Individual
Prefix:DR
First Name:GINIE
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19204 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6168
Mailing Address - Country:US
Mailing Address - Phone:352-732-6599
Mailing Address - Fax:
Practice Address - Street 1:19204 E PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432-6168
Practice Address - Country:US
Practice Address - Phone:352-732-6599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME137891207R00000X
GA056272207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I113476OtherMEDICARE PTAN
GA003127403BMedicaid