Provider Demographics
NPI:1871519819
Name:CHAN, GILBERT LAVARIAS (PT)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:LAVARIAS
Last Name:CHAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NEWHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-5624
Mailing Address - Country:US
Mailing Address - Phone:631-813-2143
Mailing Address - Fax:888-552-6176
Practice Address - Street 1:145 DREISER LOOP
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-2704
Practice Address - Country:US
Practice Address - Phone:718-671-2955
Practice Address - Fax:888-583-1385
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0281522251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400105691OtherNGS MEDICARE