Provider Demographics
NPI:1366425548
Name:CHAN, EDWARD I (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:I
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2433 CENTRAL AVE
Mailing Address - Street 2:STE A
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-6562
Mailing Address - Country:US
Mailing Address - Phone:510-521-2300
Mailing Address - Fax:510-521-7947
Practice Address - Street 1:2433 CENTRAL AVE
Practice Address - Street 2:STE A
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-6562
Practice Address - Country:US
Practice Address - Phone:510-521-2300
Practice Address - Fax:510-521-7947
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA74119207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A741190OtherBLUE SHIELD OF CA PIN
CA00A741190Medicaid
CA00A741190Medicaid
CABC7234127OtherDEA CERT #
CA00A741190OtherBLUE SHIELD OF CA PIN