Provider Demographics
NPI:1871554105
Name:PON-SANG CHAN MD INC
Entity type:Organization
Organization Name:PON-SANG CHAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PON-SANG
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-591-2118
Mailing Address - Street 1:321 N KUAKINI ST STE 704
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2362
Mailing Address - Country:US
Mailing Address - Phone:808-591-2118
Mailing Address - Fax:808-593-0922
Practice Address - Street 1:321 N KUAKINI ST STE 704
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2362
Practice Address - Country:US
Practice Address - Phone:808-591-2118
Practice Address - Fax:808-593-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 4414261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI521535Medicaid
HIC1234-8OtherHMSA
HIHPCHAN002Medicare ID - Type Unspecified
HI01176901Medicaid