Provider Demographics
NPI:1699764761
Name:CHAN, EDMOND (MD)
Entity type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:
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 1:15708 POMERADO RD
Mailing Address - Street 2:SUITE N107
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-2066
Mailing Address - Country:US
Mailing Address - Phone:858-485-5921
Mailing Address - Fax:
Practice Address - Street 1:15708 POMERADO RD
Practice Address - Street 2:SUITE N107
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2066
Practice Address - Country:US
Practice Address - Phone:858-485-5921
Practice Address - Fax:858-485-1445
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41561208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89731Medicare UPIN
G41561Medicare ID - Type Unspecified