Healthcare Provider Details

I. General information

NPI: 1295753473
Provider Name (Legal Business Name): MELANIE M CHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 MAREBLU
ALISO VIEJO CA
92656-3015
US

IV. Provider business mailing address

2742 DOW AVE
TUSTIN CA
92780-7242
US

V. Phone/Fax

Practice location:
  • Phone: 949-448-0656
  • Fax: 949-425-2465
Mailing address:
  • Phone: 714-665-1661
  • Fax: 714-665-1669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA89423
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: