Healthcare Provider Details

I. General information

NPI: 1528828506
Provider Name (Legal Business Name): SIMON CHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 04/24/2025
Certification Date: 04/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 N CALIFORNIA ST
STOCKTON CA
95204-6019
US

IV. Provider business mailing address

1800 N CALIFORNIA ST
STOCKTON CA
95204-6019
US

V. Phone/Fax

Practice location:
  • Phone: 209-547-5716
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number1528828506
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: