=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518372093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND CHAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2014
-----------------------------------------------------
Last Update Date | 07/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N PEPPER AVE
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-580-3370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10945 LE CONTE AVE STE 2339
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90095-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-825-5421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QG0300X
-----------------------------------------------------
Taxonomy Name | Geriatric Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | A148110
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------