Provider Demographics
NPI:1457925109
Name:SANNY K CHAN, MD, PHD, INC
Entity Type:Organization
Organization Name:SANNY K CHAN, MD, PHD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SANNY
Authorized Official - Middle Name:K
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:720-515-9810
Mailing Address - Street 1:1301 20TH ST STE 220
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2080
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 20TH ST STE 220
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2080
Practice Address - Country:US
Practice Address - Phone:310-401-1434
Practice Address - Fax:310-453-8468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO346419YLSHOtherMEDICARE PIN
CA1043449788Medicaid
CO333357366Medicaid