Healthcare Provider Details

I. General information

NPI: 1154873545
Provider Name (Legal Business Name): CAMILLE C CHAN D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 E MATTHEWS AVE STE 101
JONESBORO AR
72401-4356
US

IV. Provider business mailing address

PO BOX 1960
JONESBORO AR
72403-1960
US

V. Phone/Fax

Practice location:
  • Phone: 870-936-8000
  • Fax: 870-934-3663
Mailing address:
  • Phone: 870-936-8000
  • Fax: 870-934-3663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-11422
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: