Provider Demographics
NPI:1669437380
Name:CHAN, LAWRENCE W (MD)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:W
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 1:990 W FREMONT AVE
Mailing Address - Street 2:SUITE W
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-3021
Mailing Address - Country:US
Mailing Address - Phone:408-738-0378
Mailing Address - Fax:408-738-0318
Practice Address - Street 1:990 W FREMONT AVE
Practice Address - Street 2:SUITE W
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-3021
Practice Address - Country:US
Practice Address - Phone:408-738-0378
Practice Address - Fax:408-738-0318
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-18
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA63513174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH40224Medicare UPIN