Provider Demographics
NPI:1104965375
Name:CHAN, ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:
Last Name:CHAN
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:PO BOX 2113
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-7213
Mailing Address - Country:US
Mailing Address - Phone:626-288-8759
Mailing Address - Fax:626-573-8597
Practice Address - Street 1:8150 GARVEY AVE
Practice Address - Street 2:SUITE 103A
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-2472
Practice Address - Country:US
Practice Address - Phone:626-288-8759
Practice Address - Fax:626-573-8597
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73468207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G734680Medicaid
CA00G734681Medicaid
CAG73468AMedicare ID - Type Unspecified
CA00G734680Medicaid
F79928Medicare UPIN