Healthcare Provider Details

I. General information

NPI: 1609805977
Provider Name (Legal Business Name): DANIEL KAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/12/2021
Certification Date: 07/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4056 E SR 44
WILDWOOD FL
34785-7486
US

IV. Provider business mailing address

753 HIGHWAY 466
LADY LAKE FL
32159-6340
US

V. Phone/Fax

Practice location:
  • Phone: 352-268-0003
  • Fax: 855-642-1129
Mailing address:
  • Phone: 352-268-0003
  • Fax: 855-642-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD0000038597
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberME41683
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: