Healthcare Provider Details

I. General information

NPI: 1336235811
Provider Name (Legal Business Name): IAN CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MISSION BLVD STE 2200
JACKSON CA
95642-2536
US

IV. Provider business mailing address

10565 HOSPITAL WAY, BLDG 647 CARDIOLOGY DEPARTMENT
MATHER CA
95655
US

V. Phone/Fax

Practice location:
  • Phone: 209-223-5445
  • Fax:
Mailing address:
  • Phone: 916-366-5391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD045837L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG88682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: