Provider Demographics
NPI:1487689188
Name:FAN, PAUL C (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:C
Last Name:FAN
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 1:1516 COTNER AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3303
Mailing Address - Country:US
Mailing Address - Phone:310-445-2951
Mailing Address - Fax:310-479-1459
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2951
Practice Address - Fax:310-479-1459
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG626192085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00F626190OtherBLUE SHIELD
CA00G626190Medicaid
CAWG62619HMedicare PIN
CAWG62619AMedicare PIN
CA00G626194Medicare PIN
CAWG62619QMedicare PIN
CAWG62619NMedicare PIN
CA00F626190OtherBLUE SHIELD
CA00G626190Medicaid
CATG256AMedicare PIN
CAWG62619FMedicare PIN
CAWG62619JMedicare PIN
CAWG62619MMedicare PIN
CAWG62619PMedicare PIN
CATP009Medicare PIN
CA00G626192Medicare PIN
CAWG62619GMedicare PIN
CA00G626193Medicare PIN
CAWG62619IMedicare PIN
CAF34960Medicare UPIN
CAWG62619KMedicare PIN
CAWG62619LMedicare PIN
CAWG62619OMedicare PIN
CA00G626191Medicare PIN