Provider Demographics
NPI:1881872661
Name:ROGER CHAN MD A MEDICAL CORP.
Entity type:Organization
Organization Name:ROGER CHAN MD A MEDICAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-288-8759
Mailing Address - Street 1:PO BOX 2113
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-7213
Mailing Address - Country:US
Mailing Address - Phone:626-288-8759
Mailing Address - Fax:626-573-8597
Practice Address - Street 1:8150 GARVEY AVE
Practice Address - Street 2:SUITE 103A
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2472
Practice Address - Country:US
Practice Address - Phone:626-288-8759
Practice Address - Fax:626-573-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73468207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G734681Medicaid
CA00G734680Medicaid
CA00G734681Medicaid
G73468Medicare PIN
G73468AMedicare PIN