Healthcare Provider Details

I. General information

NPI: 1114868890
Provider Name (Legal Business Name): DOUGLAS CHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2026
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4102 PINION DR
USAF ACADEMY CO
80840-2502
US

IV. Provider business mailing address

3 ROBIN RD
HOLMDEL NJ
07733-1918
US

V. Phone/Fax

Practice location:
  • Phone: 719-333-5192
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDEN.00206735
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: