Provider Demographics
NPI:1902031545
Name:CHAN, MELISSA M (MD)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:M
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 1:2605 E 3300 S
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2728
Mailing Address - Country:US
Mailing Address - Phone:801-872-8846
Mailing Address - Fax:801-449-0982
Practice Address - Street 1:2605 E 3300 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84109
Practice Address - Country:US
Practice Address - Phone:801-872-8846
Practice Address - Fax:801-449-0982
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-27
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10364990-1205207Q00000X, 208M00000X
UTXC3767704207QA0401X
CAA121675207Q00000X
FLME108391207Q00000X
FL13484207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist