Provider Demographics
NPI:1285173906
Name:CHAN, CLARENCE WING-CHUNG
Entity type:Individual
Prefix:
First Name:CLARENCE
Middle Name:WING-CHUNG
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 HARVESTER DR STE 110
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-6686
Mailing Address - Country:US
Mailing Address - Phone:773-702-1150
Mailing Address - Fax:
Practice Address - Street 1:5841 S MARYLAND AVE # MC3083
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1443
Practice Address - Country:US
Practice Address - Phone:773-834-7708
Practice Address - Fax:773-834-7644
Is Sole Proprietor?:No
Enumeration Date:2017-02-14
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.076688207ZC0006X
IL036164346207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology