Healthcare Provider Details

I. General information

NPI: 1801850953
Provider Name (Legal Business Name): JACKIE TSZ-KIT CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/14/2006
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 E ORANGEBURG AVE STE A
MODESTO CA
95350-5369
US

IV. Provider business mailing address

4120 DALE RD STE J-8 #232
MODESTO CA
95356-9239
US

V. Phone/Fax

Practice location:
  • Phone: 209-529-4422
  • Fax: 209-529-1711
Mailing address:
  • Phone: 209-529-4422
  • Fax: 209-529-1711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberG077865
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberG077865
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG077865
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberG077865
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberG077865
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: