Provider Demographics
NPI:1982944005
Name:CHAN, DAVID MANFOOK (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MANFOOK
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 FOOTHILL BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2905
Mailing Address - Country:US
Mailing Address - Phone:909-596-1941
Mailing Address - Fax:
Practice Address - Street 1:11815 KNIGHTSBRIDGE PL
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-4167
Practice Address - Country:US
Practice Address - Phone:909-641-6882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28474Medicare UPIN