Provider Demographics
NPI:1720262835
Name:FAN, VIVIAN W
Entity Type:Individual
Prefix:MISS
First Name:VIVIAN
Middle Name:W
Last Name:FAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VIVIAN
Other - Middle Name:WEI-YI
Other - Last Name:FAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:21958 64TH AVE
Mailing Address - Street 2:APT#C
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-2246
Mailing Address - Country:US
Mailing Address - Phone:718-631-5245
Mailing Address - Fax:
Practice Address - Street 1:5508 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-1221
Practice Address - Country:US
Practice Address - Phone:718-418-3841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039255183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01665838Medicaid