Healthcare Provider Details

I. General information

NPI: 1871728741
Provider Name (Legal Business Name): SAMUEL C PAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2009
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 ROBBINS ST STE 2
WATERBURY CT
06708-2652
US

IV. Provider business mailing address

160 ROBBINS ST STE 2
WATERBURY CT
06708-2652
US

V. Phone/Fax

Practice location:
  • Phone: 203-756-8021
  • Fax: 203-596-9038
Mailing address:
  • Phone: 203-756-8021
  • Fax: 203-596-9038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberA120617
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number61141
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: