Provider Demographics
NPI:1932203312
Name:CHAN, THOMAS (DO)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 CARLETON AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-9029
Mailing Address - Country:US
Mailing Address - Phone:631-348-3254
Mailing Address - Fax:631-348-3031
Practice Address - Street 1:267 CARLETON AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-9029
Practice Address - Country:US
Practice Address - Phone:631-348-3254
Practice Address - Fax:631-348-3031
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2271241208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
I00655Medicare UPIN
584041Medicare ID - Type Unspecified