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NPI Code Detail

MEDICARE: ETHAN MATTHEW FAN

MEDICARE: ETHAN MATTHEW FAN
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207R00000XInternal Medicine PhysicianW0570TX

General Provider Information

NPI Number : 1649913138
Entity Type Code : Individual
Provider Name (Legal Business Name) : ETHAN MATTHEW FAN
Provider Business Mailing Address
First Line : 1140 PEACOCK BLVD
Second Line :
City : CARROLLTON
State : TX
Zip : 75007-2943
Country : US
Telephone Number : 469-471-4848
Fax Number :
Provider Business Practice Location Address
First Line : 8200 WALNUT HILL LN
Second Line :
City : DALLAS
State : TX
Zip : 75231-4402
Country : US
Telephone Number : 214-345-6176
Fax Number : 214-345-5167
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/14/2022
Last Update Date : 12/09/2025

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Directions to “ ETHAN MATTHEW FAN ” Practice Location

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