Healthcare Provider Details

I. General information

NPI: 1376170522
Provider Name (Legal Business Name): JACK CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SHATTUCK WAY STE 6
NEWINGTON NH
03801-7876
US

IV. Provider business mailing address

101 SHATTUCK WAY STE 6
NEWINGTON NH
03801-7876
US

V. Phone/Fax

Practice location:
  • Phone: 617-372-4018
  • Fax:
Mailing address:
  • Phone: 617-372-4018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number34672
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: