Healthcare Provider Details

I. General information

NPI: 1457925109
Provider Name (Legal Business Name): SANNY K CHAN, MD, PHD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 20TH ST STE 220
SANTA MONICA CA
90404-2080
US

IV. Provider business mailing address

1301 20TH ST STE 220
SANTA MONICA CA
90404-2080
US

V. Phone/Fax

Practice location:
  • Phone: 310-401-1434
  • Fax: 310-453-8468
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: SANNY K CHAN
Title or Position: CEO
Credential: MD, PHD
Phone: 720-515-9810