Healthcare Provider Details

I. General information

NPI: 1437512944
Provider Name (Legal Business Name): VINCENT CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 12/06/2021
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DUARTE RD
DUARTE CA
91010-3012
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 626-256-4673
  • Fax: 626-408-3911
Mailing address:
  • Phone: 626-256-4673
  • Fax: 626-408-3911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA156288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: