Healthcare Provider Details

I. General information

NPI: 1245963297
Provider Name (Legal Business Name): CARNEY CHAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 09/23/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 LYNN RD STE 102
THOUSAND OAKS CA
91360-8017
US

IV. Provider business mailing address

2220 LYNN RD STE 102
THOUSAND OAKS CA
91360-8017
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-9727
  • Fax: 805-496-9148
Mailing address:
  • Phone: 805-496-9727
  • Fax: 805-496-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: ANDREA WARNKE
Title or Position: BILLING MANAGER
Credential:
Phone: 805-210-2219