Basic Information
| Provider Information | |||||||||
| NPI: | 1740456847 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JOHOL C CHAN DO PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 450193 | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780450004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958236 | ||||||||
| FaxNumber: | 9567186994 | ||||||||
| Practice Location | |||||||||
| Address1: | 7210 MCPHERSON RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780416505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567958236 | ||||||||
| FaxNumber: | 9567186994 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2008 | ||||||||
| LastUpdateDate: | 06/30/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHAN | ||||||||
| AuthorizedOfficialFirstName: | JOHOL | ||||||||
| AuthorizedOfficialMiddleName: | CHO-HONG | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9567958236 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | K1389 | TX | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 159242001 | 05 | TX | MEDICAID | D05769 | 01 | TX | PALMETTO GBA (MEDICARE RAILROAD) | OTHER |