Provider Demographics
NPI:1487796850
Name:CHAN, JOHNSON C (MD)
Entity type:Individual
Prefix:
First Name:JOHNSON
Middle Name:C
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 W MERRICK ROAD
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520
Mailing Address - Country:US
Mailing Address - Phone:516-868-8333
Mailing Address - Fax:516-868-1053
Practice Address - Street 1:190 W MERRICK ROAD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520
Practice Address - Country:US
Practice Address - Phone:516-868-8333
Practice Address - Fax:516-868-1053
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY125002207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00398045Medicaid
NY00398045Medicaid
C11767Medicare UPIN