Healthcare Provider Details

I. General information

NPI: 1508286915
Provider Name (Legal Business Name): KEVIN GAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S IDAHO ST
LA HABRA CA
90631-6047
US

IV. Provider business mailing address

2021 S AUGUSTA CT
LA HABRA CA
90631-2013
US

V. Phone/Fax

Practice location:
  • Phone: 562-690-0400
  • Fax:
Mailing address:
  • Phone: 714-684-4487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA149518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: