Healthcare Provider Details

I. General information

NPI: 1902031545
Provider Name (Legal Business Name): MELISSA M. CHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 10/15/2024
Certification Date: 09/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 S MAIN ST
SALT LAKE CITY UT
84115-1951
US

IV. Provider business mailing address

1776 S MAIN ST
SALT LAKE CITY UT
84115-1951
US

V. Phone/Fax

Practice location:
  • Phone: 801-872-8846
  • Fax: 801-449-0982
Mailing address:
  • Phone: 801-872-8846
  • Fax: 801-449-0982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13484
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA121675
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME108391
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberXC3767704
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number10364990-1205
License Number StateUT
# 6
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10364990-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: