Healthcare Provider Details

I. General information

NPI: 1295001972
Provider Name (Legal Business Name): KEITH TED CHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 10/15/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 FAWCETT AVE STE 100
TACOMA WA
98402-1900
US

IV. Provider business mailing address

533 S 336TH ST STE C
FEDERAL WAY WA
98003-6329
US

V. Phone/Fax

Practice location:
  • Phone: 253-761-4200
  • Fax: 253-761-4201
Mailing address:
  • Phone: 253-661-1700
  • Fax: 253-661-4565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberML 60286792
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD60384220
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD60384220
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: