=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831488618
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN KEN-CHEE CHAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2011
-----------------------------------------------------
Last Update Date | 08/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 E ROLLINS ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-975-0410
-----------------------------------------------------
Fax | 407-975-0411
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 E ROLLINS ST
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-1248
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-975-0410
-----------------------------------------------------
Fax | 407-975-0411
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | MD043305
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD043305
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2080P0203X
-----------------------------------------------------
Taxonomy Name | Pediatric Critical Care Medicine Physician
-----------------------------------------------------
License Number | ME135899
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------