Provider Demographics
NPI:1205133121
Name:ELLEN PAN MD PC
Entity type:Organization
Organization Name:ELLEN PAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-236-7772
Mailing Address - Street 1:8301 BAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-2666
Mailing Address - Country:US
Mailing Address - Phone:718-236-7772
Mailing Address - Fax:
Practice Address - Street 1:8301 BAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2666
Practice Address - Country:US
Practice Address - Phone:718-236-7772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136911207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00589708-9Medicaid
NY48A701Medicare PIN