Healthcare Provider Details

I. General information

NPI: 1184612210
Provider Name (Legal Business Name): CHYANSONG J TZAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S GRAND AVE
GLENDORA CA
91741-4218
US

IV. Provider business mailing address

PO BOX 788
HEMET CA
92546-0788
US

V. Phone/Fax

Practice location:
  • Phone: 626-963-8411
  • Fax:
Mailing address:
  • Phone: 951-929-6260
  • Fax: 951-765-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberL0669
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberC52948
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: