Provider Demographics
NPI:1043326283
Name:CHAN, MICHELLE L (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:CHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1726 NEW AVE
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-3734
Mailing Address - Country:US
Mailing Address - Phone:626-943-0780
Mailing Address - Fax:626-943-0200
Practice Address - Street 1:1726 NEW AVE
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3734
Practice Address - Country:US
Practice Address - Phone:626-943-0780
Practice Address - Fax:626-943-0200
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA177343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A547860Medicaid
CAG71002Medicare UPIN