1669558508 NPI number — DR. ANTONIO QUAN CHAN M.D.

Table of content: DR. ANTONIO QUAN CHAN M.D. (NPI 1669558508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669558508 NPI number — DR. ANTONIO QUAN CHAN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
ANTONIO
Provider Middle Name:
QUAN
Provider Name Prefix Text:
DR.
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:
ANTHONY
Provider Other Middle Name:
QUAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1669558508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3726 LAS VEGAS BLVD S UNIT 3501W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89158-4399
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-882-6740
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1289 S. PARK VICTORIA DRIVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MILPITAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95035-6974
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-586-8866
Provider Business Practice Location Address Fax Number:
408-586-8858
Provider Enumeration Date:
10/31/2006

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: 207RC0000X , with the licence number:  A35593 , 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: 00A355930 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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