Provider Demographics
NPI:1063779015
Name:CHAICHANA, KHAN (MD)
Entity type:Individual
Prefix:
First Name:KHAN
Middle Name:
Last Name:CHAICHANA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3157 SW FAIRMOUNT BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-1441
Mailing Address - Country:US
Mailing Address - Phone:801-414-5090
Mailing Address - Fax:
Practice Address - Street 1:3157 SW FAIRMOUNT BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-1441
Practice Address - Country:US
Practice Address - Phone:801-414-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA266820207L00000X
ORMD184749207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500733898Medicaid