Provider Demographics
NPI:1336235811
Name:CHAN, IAN (MD)
Entity Type:Individual
Prefix:
First Name:IAN
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 1:10565 HOSPITAL WAY, BLDG 647
Mailing Address - Street 2:CARDIOLOGY DEPARTMENT
Mailing Address - City:MATHER
Mailing Address - State:CA
Mailing Address - Zip Code:95655
Mailing Address - Country:US
Mailing Address - Phone:916-366-5391
Mailing Address - Fax:
Practice Address - Street 1:10565 HOSPITAL WAY, BLDG 647
Practice Address - Street 2:CARDIOLOGY DEPARTMENT
Practice Address - City:MATHER
Practice Address - State:CA
Practice Address - Zip Code:95655
Practice Address - Country:US
Practice Address - Phone:916-366-5391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045837L207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001296384Medicaid
PAA61753Medicare UPIN
PA712421Medicare ID - Type Unspecified