Provider Demographics
NPI:1306874169
Name:CHAN, ANNIE WAIFONG (MD)
Entity type:Individual
Prefix:DR
First Name:ANNIE
Middle Name:WAIFONG
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:WAI FONG
Other - Middle Name:ANNIE
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:55 FRUIT STREET
Mailing Address - Street 2:COX 337 MASSACHUSETTS GENERAL HOSPITAL
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114
Mailing Address - Country:US
Mailing Address - Phone:617-724-1159
Mailing Address - Fax:617-726-3603
Practice Address - Street 1:100 BLOSSOMS STREET
Practice Address - Street 2:COX LL MASSACHUSETTS GENERAL HOSPITAL,
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-724-1159
Practice Address - Fax:617-726-3603
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2053152085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA205315OtherTUFTS HEALTH PLAN
MA0117170Medicaid
MAJ22411OtherBCBS MA
H21688Medicare UPIN
MAJ22411OtherBCBS MA