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General NPI Number Information
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NPI Number | 1700100781
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Entity Type | Organization
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Legal Business Name | ERIC FAN, M.D. LLC
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Dates
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Enumeration Date | 03/20/2010
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Last Update Date | 03/20/2010
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Provider Practice Location Address
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Address Line | 200 ORCHARD ST SUITE 303
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City | NEW HAVEN
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State | CT
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Zip | 06511-5363
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Country | US
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Telephone | 203-867-5600
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Fax | 203-867-5604
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Provider Business Mailing Address
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Address Line | 200 ORCHARD ST SUITE 303
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City | NEW HAVEN
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State | CT
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Zip | 06511-5363
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Country | US
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Telephone | 203-867-5600
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Fax | 203-867-5604
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Authorized Official
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Title or Position | MANAGER
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Name | DR. ERIC FAN
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Credential | M.D.
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Telephone | 203-867-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 038797
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License Number State | CT
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