Provider Demographics
NPI:1861473605
Name:CHAN, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4943
Practice Address - Street 1:4211 VANDYKE ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8004
Practice Address - Country:US
Practice Address - Phone:813-264-6490
Practice Address - Fax:813-321-1878
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0073332207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252779100Medicaid
FLCS426ZMedicare PIN
FLG60484Medicare UPIN