Provider Demographics
NPI:1053427427
Name:CHAN, EDWIN TAK-WING (MD)
Entity type:Individual
Prefix:
First Name:EDWIN
Middle Name:TAK-WING
Last Name:CHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EDWIN
Other - Middle Name:TAK WING
Other - Last Name:CHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:624 W DUARTE RD
Mailing Address - Street 2:208
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-7603
Mailing Address - Country:US
Mailing Address - Phone:626-446-3608
Mailing Address - Fax:626-446-3817
Practice Address - Street 1:624 W DUARTE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-7603
Practice Address - Country:US
Practice Address - Phone:626-446-3608
Practice Address - Fax:626-446-3817
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA66464Medicaid
CAA66464Medicaid