Provider Demographics
NPI:1962410951
Name:CHAN, JUANCHO SALAZAR (MD)
Entity type:Individual
Prefix:DR
First Name:JUANCHO
Middle Name:SALAZAR
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:11 MARSHALL RD
Mailing Address - Street 2:STE 1G
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590
Mailing Address - Country:US
Mailing Address - Phone:845-298-8044
Mailing Address - Fax:845-298-8402
Practice Address - Street 1:11 MARSHALL RD
Practice Address - Street 2:STE 1G
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590
Practice Address - Country:US
Practice Address - Phone:845-298-8044
Practice Address - Fax:845-298-8402
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY167496208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00972601Medicaid
NY78D311Medicare ID - Type Unspecified
A64291Medicare UPIN