MEDICARE: ELLEN FAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0805X	Geriatric Psychiatry Physician	K8897	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134153646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLEN FAN M.D.

Provider Business Mailing Address
First Line	:	3308 PRESTON RD
Second Line	:	SUITE 350 BOX 242
City	:	PLANO
State	:	TX
Zip	:	75093-7453
Country	:	US
Telephone Number	:	972-769-8572
Fax Number	:	972-769-8591

Provider Business Practice Location Address
First Line	:	3308 PRESTON RD
Second Line	:	SUITE 350 BOX 242
City	:	PLANO
State	:	TX
Zip	:	75093-7453
Country	:	US
Telephone Number	:	972-769-8572
Fax Number	:	972-769-8591

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	06/05/2013

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Directions to “ ELLEN FAN M.D.” Practice Location

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