Healthcare Provider Details

I. General information

NPI: 1124142054
Provider Name (Legal Business Name): EDWIN CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2007
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 ELDRON BLVD SE
PALM BAY FL
32909-6831
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-576-0645
  • Fax: 321-409-6812
Mailing address:
  • Phone: 321-576-0645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME104439
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: