Provider Demographics
NPI:1871713271
Name:CHAN, JEFFERSON Y (MD, PHD)
Entity type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:Y
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 513377
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3377
Mailing Address - Country:US
Mailing Address - Phone:714-456-8835
Mailing Address - Fax:714-456-6248
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-6141
Practice Address - Fax:714-456-5873
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84497207ZP0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG84497AOtherMEDICARE PTAN
CA00G844970Medicaid
CA00G844970OtherBLUE SHIELD
H49046Medicare UPIN
CA00G844970Medicaid