Basic Information
| Provider Information | |||||||||
| NPI: | 1962799858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | BENNETT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 WALKER ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100134135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122268866 | ||||||||
| FaxNumber: | 2122262289 | ||||||||
| Practice Location | |||||||||
| Address1: | 13626 37TH AVE | ||||||||
| Address2: | |||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113546533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188861212 | ||||||||
| FaxNumber: | 7188867576 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 06/05/2019 | ||||||||
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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 | 208000000X | 274644 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 03924361 | 05 | NY | MEDICAID |