MEDICARE: TIFFANY L CHAN 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	2085R0202X	Diagnostic Radiology Physician	A154773	CA

General Provider Information

NPI Number	:	1457796518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY L CHAN M.D.

Provider Business Mailing Address
First Line	:	5767 W CENTURY BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-5631
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	757 WESTWOOD PLZ STE 1638
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90095-3412
Country	:	US
Telephone Number	:	310-267-8796
Fax Number	:	310-267-2059

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

Provider Enumeration Date	:	05/02/2013
Last Update Date	:	12/10/2019

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