Provider Demographics
NPI:1922190388
Name:CHAN, TERESA T (MD)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:T
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 1:260 E BROADWAY STE 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10002-5609
Mailing Address - Country:US
Mailing Address - Phone:212-777-4329
Mailing Address - Fax:212-777-4301
Practice Address - Street 1:260 E BROADWAY STE 2
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-5609
Practice Address - Country:US
Practice Address - Phone:212-777-4329
Practice Address - Fax:212-777-4301
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2013-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2139581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02230335Medicaid
H91092Medicare UPIN
NY02230335Medicaid