Provider Demographics
NPI:1043639222
Name:CHAN, TONY
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:CHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 FAIRMONT DR STE A
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-3547
Mailing Address - Country:US
Mailing Address - Phone:510-519-6429
Mailing Address - Fax:864-810-6629
Practice Address - Street 1:2940 SUMMIT ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3416
Practice Address - Country:US
Practice Address - Phone:510-519-6429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2018-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10436392222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry