Healthcare Provider Details

I. General information

NPI: 1588714430
Provider Name (Legal Business Name): JOANNA CHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 02/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3918 LONG BEACH BLVD. SUITE 200
LONG BEACH CA
90807
US

IV. Provider business mailing address

3918 LONG BEACH BLVD. SUITE 200
LONG BEACH CA
90807
US

V. Phone/Fax

Practice location:
  • Phone: 562-997-1144
  • Fax: 562-997-9881
Mailing address:
  • Phone: 562-997-1144
  • Fax: 562-997-9881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberN1579
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA110959
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License NumberA110959
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: