Basic Information
| Provider Information | |||||||||
| NPI: | 1417918343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | JEFFREY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313917889 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8906 135TH ST | ||||||||
| Address2: | SUITE 2T | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067110 | ||||||||
| FaxNumber: | 7182067111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 02/14/2014 | ||||||||
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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 | 208600000X | 206686 | NY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 01755004 | 05 | NY | MEDICAID |