Provider Demographics
NPI:1306161179
Name:CHAN, AUDREY JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JACQUELINE
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 KIRBY DR
Mailing Address - Street 2:APT. 633
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-4300
Mailing Address - Country:US
Mailing Address - Phone:443-618-1578
Mailing Address - Fax:
Practice Address - Street 1:6701 FANNIN ST
Practice Address - Street 2:SUITE 670
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2608
Practice Address - Country:US
Practice Address - Phone:832-822-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ0233207NP0225X, 208000000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207N00000XAllopathic & Osteopathic PhysiciansDermatology