Healthcare Provider Details

I. General information

NPI: 1629191663
Provider Name (Legal Business Name): ERIC C FAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2007
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 11TH AVE
ALBANY GA
31701-1645
US

IV. Provider business mailing address

103 LAUREL OAK LN
THOMASVILLE GA
31792-7647
US

V. Phone/Fax

Practice location:
  • Phone: 850-766-6566
  • Fax: 229-233-0927
Mailing address:
  • Phone: 850-766-6566
  • Fax: 229-233-0927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number49615
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: