Healthcare Provider Details

I. General information

NPI: 1720283294
Provider Name (Legal Business Name): KATHERINE W FAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20380 TOWN CENTER LN STE 215
CUPERTINO CA
95014-3250
US

IV. Provider business mailing address

4688 LA CRESCENT LOOP
SAN JOSE CA
95136-2685
US

V. Phone/Fax

Practice location:
  • Phone: 408-996-7950
  • Fax:
Mailing address:
  • Phone: 408-427-2872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD429247
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD429247
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD429247
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA104114
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: