Basic Information
| Provider Information | |||||||||
| NPI: | 1982109138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHAN | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156002402 | ||||||||
| FaxNumber: | 4153691292 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 WEBSTER ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941152373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156002402 | ||||||||
| FaxNumber: | 4153691292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2018 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 1261389 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | A163949 | 01 | CA | STATE MEDICAL LICENSE | OTHER |