Healthcare Provider Details

I. General information

NPI: 1790818177
Provider Name (Legal Business Name): KEVIN W CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 03/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 TECH CENTER DR STE 210
SACRAMENTO CA
95826-2589
US

IV. Provider business mailing address

9300 TECH CENTER DR STE 210
SACRAMENTO CA
95826-2589
US

V. Phone/Fax

Practice location:
  • Phone: 916-379-9300
  • Fax:
Mailing address:
  • Phone: 916-379-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberG70023
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: