Provider Demographics
NPI:1831446665
Name:CHAN, FONDA
Entity type:Individual
Prefix:
First Name:FONDA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GARDNER ST APT 11
Mailing Address - Street 2:
Mailing Address - City:ALLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02134-2236
Mailing Address - Country:US
Mailing Address - Phone:410-258-8336
Mailing Address - Fax:
Practice Address - Street 1:8390 LYNDON B JOHNSON FWY STE 1000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-1288
Practice Address - Country:US
Practice Address - Phone:214-750-9977
Practice Address - Fax:214-750-9983
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252590207R00000X
TXR69852084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine