Provider Demographics
NPI:1801109624
Name:WILLIAM HENRY CHAN M D PROFESSIONAL CORP.
Entity type:Organization
Organization Name:WILLIAM HENRY CHAN M D PROFESSIONAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:916-421-1772
Mailing Address - Street 1:5525 ASSEMBLY CT
Mailing Address - Street 2:BLDG. C
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-2634
Mailing Address - Country:US
Mailing Address - Phone:916-421-1772
Mailing Address - Fax:916-421-0635
Practice Address - Street 1:5525 ASSEMBLY CT
Practice Address - Street 2:BLDG C
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2634
Practice Address - Country:US
Practice Address - Phone:916-421-1772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-21
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA20775174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A207750OtherPTAN
A22325Medicare UPIN