Provider Demographics
NPI:1699702324
Name:CHAN, GARY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GARY
Other - Middle Name:LEE
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:909 HYDE ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94109-4822
Mailing Address - Country:US
Mailing Address - Phone:415-474-7900
Mailing Address - Fax:415-474-7930
Practice Address - Street 1:909 HYDE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-4822
Practice Address - Country:US
Practice Address - Phone:415-474-7900
Practice Address - Fax:415-474-7930
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34576207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45982Medicare UPIN
CA00G345760Medicare ID - Type Unspecified