Healthcare Provider Details

I. General information

NPI: 1942299839
Provider Name (Legal Business Name): CANCER CARE ASSOCIATES MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 W 6TH ST STE #315
SAN PEDRO CA
90732-3581
US

IV. Provider business mailing address

514 N PROSPECT AVE 4TH FLOOR
REDONDO BEACH CA
90277-3040
US

V. Phone/Fax

Practice location:
  • Phone: 310-750-3300
  • Fax: 310-750-3381
Mailing address:
  • Phone: 310-750-3300
  • Fax: 310-750-3381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberFNP17913
License Number StateCA

VIII. Authorized Official

Name: DAVID CHAN
Title or Position: CO OWNER PRESIDENT
Credential: MD
Phone: 310-750-3300