Provider Demographics
NPI:1639178460
Name:CHAN, KENNETH KWOK-CHUN (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KWOK-CHUN
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:ANDOVER PEDIATRICS NPI 1548393176
Mailing Address - Street 2:203 TURNPIKE ST, SUITE 200
Mailing Address - City:NORTH ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01845
Mailing Address - Country:US
Mailing Address - Phone:978-475-4522
Mailing Address - Fax:978-475-6531
Practice Address - Street 1:ANDOVER PEDIATRICS NPI 1548393176
Practice Address - Street 2:203 TURNPIKE ST, SUITE 200
Practice Address - City:NORTH ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01845
Practice Address - Country:US
Practice Address - Phone:978-475-4522
Practice Address - Fax:978-475-6531
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA205542208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0124010Medicaid
MA11002050AMedicaid
MA0124010Medicaid