Provider Demographics
NPI:1871532945
Name:CHAN, MARK H (MD)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:H
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 GRAND AVE
Mailing Address - Street 2:SUITE 610
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3725
Mailing Address - Country:US
Mailing Address - Phone:510-835-0235
Mailing Address - Fax:510-835-0298
Practice Address - Street 1:80 GRAND AVE
Practice Address - Street 2:SUITE 610
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3725
Practice Address - Country:US
Practice Address - Phone:510-835-0235
Practice Address - Fax:510-835-0298
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84716174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75981Medicare UPIN
CA00G847160Medicare ID - Type Unspecified