Healthcare Provider Details

I. General information

NPI: 1710291307
Provider Name (Legal Business Name): WAI BEN CHAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2010
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MARTER AVE
MOORESTOWN NJ
08057-3124
US

IV. Provider business mailing address

110 MARTER AVE
MOORESTOWN NJ
08057-3124
US

V. Phone/Fax

Practice location:
  • Phone: 856-608-8840
  • Fax: 856-722-1898
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB09368400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number266942-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: