Provider Demographics
NPI:1265437842
Name:CHAN, TAK (MD)
Entity type:Individual
Prefix:DR
First Name:TAK
Middle Name:
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 1:13338 41ST RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3661
Mailing Address - Country:US
Mailing Address - Phone:718-445-7788
Mailing Address - Fax:718-445-7789
Practice Address - Street 1:13338 41ST RD
Practice Address - Street 2:STE 2C
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3661
Practice Address - Country:US
Practice Address - Phone:718-445-7788
Practice Address - Fax:718-445-7789
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2012-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204551207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01888839Medicaid
NY01888839Medicaid
NY06481Medicare PIN