MEDICARE: CHAN M MA MD

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	207RN0300X	Nephrology Physician	180042	NY

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	:	1487642120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHAN M MA MD

Provider Business Mailing Address
First Line	:	7705 SHORE ROAD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209
Country	:	US
Telephone Number	:	718-715-8674
Fax Number	:	212-966-0072

Provider Business Practice Location Address
First Line	:	128 MOTT ST
Second Line	:	SUITE 405
City	:	NEW YORK
State	:	NY
Zip	:	10013-5540
Country	:	US
Telephone Number	:	212-966-0068
Fax Number	:	212-966-0072

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	03/19/2025

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Directions to “ CHAN M MA MD” Practice Location

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