Provider Demographics
NPI:1972618866
Name:CHAN, IRA CARL (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:CARL
Last Name:CHAN
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 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:301 OLD SAN FRANCISCO RD
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94086-6386
Practice Address - Country:US
Practice Address - Phone:408-730-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG133888207V00000X
MA79490207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110055650Medicaid
MA989800OtherNETWORK HEALTH
MAAA96851OtherHARVARD PILGRIM
MAJ31017OtherBCBS
MA34650OtherBMC HEALTHNET
MA603957OtherTUFTS
MA110055650Medicaid