Healthcare Provider Details

I. General information

NPI: 1811073166
Provider Name (Legal Business Name): JEN-JUNG PAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 N 12TH ST FL 2
PHOENIX AZ
85006-2837
US

IV. Provider business mailing address

1441 N 12TH ST FL 2
PHOENIX AZ
85006-2837
US

V. Phone/Fax

Practice location:
  • Phone: 602-521-5180
  • Fax:
Mailing address:
  • Phone: 602-521-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2009008670
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberN6556
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number54235
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: