Provider Demographics
NPI:1245260538
Name:FAN, WARREN C (MD)
Entity type:Individual
Prefix:
First Name:WARREN
Middle Name:C
Last Name:FAN
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 1:637 N 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4906
Mailing Address - Country:US
Mailing Address - Phone:909-946-4106
Mailing Address - Fax:909-949-4366
Practice Address - Street 1:637 NORTH 13TH AVENUE
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786
Practice Address - Country:US
Practice Address - Phone:909-946-4106
Practice Address - Fax:909-949-4366
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32805171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A328050Medicaid
CAA26935Medicare UPIN
CA00A328050Medicare ID - Type Unspecified