Provider Demographics
NPI:1851407787
Name:CHAN, ROXANNE (MD)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:CHAN
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 IRVINE AVE # 782
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-4602
Mailing Address - Country:US
Mailing Address - Phone:617-251-8088
Mailing Address - Fax:
Practice Address - Street 1:1048 IRVINE AVE # 782
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-4602
Practice Address - Country:US
Practice Address - Phone:617-251-8088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1523822085R0202X, 2085R0202X
CAA822012085R0202X
TXP29672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A822010Medicaid
CA00A822010Medicaid
CA00A822010Medicare PIN