Provider Demographics
NPI:1336349216
Name:CHAN, TERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRY
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 1:5 CENTRE POINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA PALMA
Mailing Address - State:CA
Mailing Address - Zip Code:90623-1604
Mailing Address - Country:US
Mailing Address - Phone:714-562-3420
Mailing Address - Fax:714-562-3496
Practice Address - Street 1:5 CENTRE POINT DRIVE
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1604
Practice Address - Country:US
Practice Address - Phone:714-562-3420
Practice Address - Fax:714-562-3496
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ40481207Q00000X
CAA98854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122846Medicare PIN
AZZ147507Medicare PIN