Healthcare Provider Details

I. General information

NPI: 1871713271
Provider Name (Legal Business Name): JEFFERSON Y CHAN M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

PO BOX 513377
LOS ANGELES CA
90051-3377
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-6141
  • Fax: 714-456-5873
Mailing address:
  • Phone: 714-456-8835
  • Fax: 714-456-6248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberG84497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: