Provider Demographics
NPI:1427361146
Name:MICHELLE L CHAN A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MICHELLE L CHAN A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-943-0780
Mailing Address - Street 1:1726 NEW AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3734
Mailing Address - Country:US
Mailing Address - Phone:626-943-0780
Mailing Address - Fax:626-943-0200
Practice Address - Street 1:1726 NEW AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3734
Practice Address - Country:US
Practice Address - Phone:626-943-0780
Practice Address - Fax:626-943-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54786207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A547860Medicaid
CA00A547860Medicaid