Basic Information
| Provider Information | |||||||||
| NPI: | 1114987526 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | TO-HANG | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6620 COYLE AVE | ||||||||
| Address2: | # 301 | ||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956086333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169612514 | ||||||||
| FaxNumber: | 9169610297 | ||||||||
| Practice Location | |||||||||
| Address1: | 6620 COYLE AVE | ||||||||
| Address2: | # 301 | ||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956086333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169612514 | ||||||||
| FaxNumber: | 9169610297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 12/16/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | A61116 | CA | N | Allopathic & Osteopathic Physicians | Urology | 174400000X | A06116 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00A611160 | 05 | CA | MEDICAID | 340017833 | 01 | CA | RAILROAD MEDICARE | OTHER |