Healthcare Provider Details

I. General information

NPI: 1053577924
Provider Name (Legal Business Name): JON MICHAEL CHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2008
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 OAKLAND PL
BUFFALO NY
14222-2041
US

IV. Provider business mailing address

65 OAKLAND PL
BUFFALO NY
14222-2041
US

V. Phone/Fax

Practice location:
  • Phone: 614-366-3687
  • Fax:
Mailing address:
  • Phone: 614-366-3687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number35.120793
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036.144383
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number293812
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMT193950
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number23031
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: