1053427427 NPI number — EDWIN TAK-WING CHAN M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053427427 NPI number — EDWIN TAK-WING CHAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
EDWIN
Provider Middle Name:
TAK-WING
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHAN
Provider Other First Name:
EDWIN
Provider Other Middle Name:
TAK WING
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1053427427
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 W DUARTE RD
Provider Second Line Business Mailing Address:
208
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91007-7603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-446-3608
Provider Business Mailing Address Fax Number:
626-446-3817

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 W DUARTE RD
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
ARCADIA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91007-7603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-446-3608
Provider Business Practice Location Address Fax Number:
626-446-3817
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  A66464 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: A66464 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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