Healthcare Provider Details

I. General information

NPI: 1548558984
Provider Name (Legal Business Name): DOUGLAS CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 PIEDMONT RD NE
ATLANTA GA
30305-1516
US

IV. Provider business mailing address

579 N SUPERIOR AVE
DECATUR GA
30033-5401
US

V. Phone/Fax

Practice location:
  • Phone: 404-351-2008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number96215
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: