Healthcare Provider Details

I. General information

NPI: 1013178433
Provider Name (Legal Business Name): JOHN CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2008
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 SMITH ST
ORANGE PARK FL
32073-5554
US

IV. Provider business mailing address

PO BOX 45443
SALT LAKE CITY UT
84145-0443
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-2140
  • Fax: 904-264-3018
Mailing address:
  • Phone: 904-202-1032
  • Fax: 904-376-4107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101246006
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME 123976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: