Provider Demographics
NPI:1134153646
Name:FAN, ELLEN (MD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:FAN
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 1:3308 PRESTON RD
Mailing Address - Street 2:SUITE 350 BOX 242
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7453
Mailing Address - Country:US
Mailing Address - Phone:972-769-8572
Mailing Address - Fax:972-769-8591
Practice Address - Street 1:3308 PRESTON RD
Practice Address - Street 2:SUITE 350 BOX 242
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7453
Practice Address - Country:US
Practice Address - Phone:972-769-8572
Practice Address - Fax:972-769-8591
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK88972084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX179655901Medicaid
TXH91609Medicare UPIN
TX179655901Medicaid
TXTXB100819Medicare PIN