Provider Demographics
NPI:1700172814
Name:SAMUEL CHAN MEDICAL,PC
Entity Type:Organization
Organization Name:SAMUEL CHAN MEDICAL,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:LOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-595-8728
Mailing Address - Street 1:3530 ATLANTIC AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-4569
Mailing Address - Country:US
Mailing Address - Phone:562-595-8728
Mailing Address - Fax:562-490-7395
Practice Address - Street 1:3530 ATLANTIC AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-4569
Practice Address - Country:US
Practice Address - Phone:562-595-8728
Practice Address - Fax:562-490-7395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2011-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26972208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty