Provider Demographics
NPI:1841371200
Name:CHAN, SAMUEL (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13091 KERRY ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92844-1638
Mailing Address - Country:US
Mailing Address - Phone:714-638-8811
Mailing Address - Fax:714-638-2799
Practice Address - Street 1:13091 KERRY ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92844-1638
Practice Address - Country:US
Practice Address - Phone:714-638-8811
Practice Address - Fax:714-638-2799
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG26972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA43163Medicare UPIN