Provider Demographics
NPI:1114129236
Name:CHAN, DAVID (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
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 1:3030 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34292-2613
Mailing Address - Country:US
Mailing Address - Phone:941-485-1505
Mailing Address - Fax:941-492-4065
Practice Address - Street 1:3030 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34292-2613
Practice Address - Country:US
Practice Address - Phone:941-485-1505
Practice Address - Fax:941-492-4065
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD443548207X00000X, 207XS0106X
FLME113787207X00000X, 207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1027535230001Medicaid
PACH245780Medicare PIN