Provider Demographics
NPI:1194710871
Name:CHAN, COLIN (MD)
Entity type:Individual
Prefix:
First Name:COLIN
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 12868
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33733-2868
Mailing Address - Country:US
Mailing Address - Phone:727-824-8357
Mailing Address - Fax:727-824-3132
Practice Address - Street 1:12450 ROOSEVELT BLVD N
Practice Address - Street 2:SUITE 101
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33716-1902
Practice Address - Country:US
Practice Address - Phone:727-571-1688
Practice Address - Fax:727-572-0900
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME73079207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL252278100Medicaid
FL252278100Medicaid
FL41530XMedicare PIN