Provider Demographics
NPI:1730195645
Name:CHAN, CONSTANT KS (MD)
Entity type:Individual
Prefix:DR
First Name:CONSTANT
Middle Name:KS
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KYI
Other - Middle Name:SEIN
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:10007 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-1514
Mailing Address - Country:US
Mailing Address - Phone:323-566-3157
Mailing Address - Fax:323-566-2676
Practice Address - Street 1:10007 STATE ST
Practice Address - Street 2:
Practice Address - City:LYNWOOD
Practice Address - State:CA
Practice Address - Zip Code:90262-1514
Practice Address - Country:US
Practice Address - Phone:323-566-3157
Practice Address - Fax:323-566-2676
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40174207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401740Medicaid
CAA40174OtherLICENSE
CAAS2258324OtherDEA
CA00A401740Medicaid
CAAS2258324OtherDEA