Healthcare Provider Details

I. General information

NPI: 1992831671
Provider Name (Legal Business Name): CHOA CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1530 E CHEVY CHASE DR #202
GLENDALE CA
91206-4163
US

IV. Provider business mailing address

1530 E CHEVY CHASE DR #202
GLENDALE CA
91206-4163
US

V. Phone/Fax

Practice location:
  • Phone: 818-244-9595
  • Fax: 818-244-9599
Mailing address:
  • Phone: 818-244-9595
  • Fax: 818-244-9599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC43036
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: