Healthcare Provider Details

I. General information

NPI: 1932203312
Provider Name (Legal Business Name): THOMAS CHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 CARLETON AVE
CENTRAL ISLIP NY
11722-9029
US

IV. Provider business mailing address

267 CARLETON AVE
CENTRAL ISLIP NY
11722-9029
US

V. Phone/Fax

Practice location:
  • Phone: 631-348-3254
  • Fax: 631-348-3031
Mailing address:
  • Phone: 631-348-3254
  • Fax: 631-348-3031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2271241
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: