Provider Demographics
NPI:1356520258
Name:GAN, CHI MENG (MD)
Entity type:Individual
Prefix:DR
First Name:CHI
Middle Name:MENG
Last Name:GAN
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-453-1039
Mailing Address - Fax:425-453-8955
Practice Address - Street 1:1200 112TH AVE NE STE C160
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-453-1039
Practice Address - Fax:425-453-8955
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042949207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8800056OtherMEDICARE PROVIDER NUMBER
WA0178441OtherLABOR AND INDUSTRIES
WA1119114Medicaid
WAG8800056OtherMEDICARE PROVIDER NUMBER