Provider Demographics
NPI:1104351352
Name:CHAN, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2341 W LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8012
Mailing Address - Country:US
Mailing Address - Phone:844-424-3668
Mailing Address - Fax:317-575-6909
Practice Address - Street 1:2341 W LINCOLN RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8012
Practice Address - Country:US
Practice Address - Phone:844-424-3668
Practice Address - Fax:317-575-6909
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN07001339A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH27-1408630OtherJEWISH HOSPITAL