Provider Demographics
NPI:1043254576
Name:CHAN, THERESA (MD)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 E BARNETT ROAD
Mailing Address - Street 2:#E-333 SOUTHERN OREGON HOSPITALISTS, PC
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-282-6770
Mailing Address - Fax:541-282-6771
Practice Address - Street 1:2825 E BARNETT ROAD
Practice Address - Street 2:ROGUE VALLEY MEDICAL CENTER
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-789-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83176207Q00000X
ORMD152431207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A831760Medicaid
CAI24889Medicare UPIN
ORR158469Medicare PIN
CA00A831761Medicare ID - Type Unspecified