Provider Demographics
NPI:1982664611
Name:CHAN, EDWIN KENNETH (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:KENNETH
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:EDWIN
Other - Middle Name:K
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 2625
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-8925
Mailing Address - Country:US
Mailing Address - Phone:718-321-8246
Mailing Address - Fax:718-321-8273
Practice Address - Street 1:13640 39TH AVE
Practice Address - Street 2:SUITE 6GB
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5536
Practice Address - Country:US
Practice Address - Phone:718-321-8246
Practice Address - Fax:718-321-8273
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-25
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222486174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02655645Medicaid
NYI28036Medicare UPIN
NY7M8201Medicare ID - Type Unspecified