1003254012 NPI number — MRS. KATHERINE LILLIAN CHAN MD

Table of content: MRS. KATHERINE LILLIAN CHAN MD (NPI 1003254012)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003254012 NPI number — MRS. KATHERINE LILLIAN CHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHAN
Provider First Name:
KATHERINE
Provider Middle Name:
LILLIAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STITELY
Provider Other First Name:
KATHERINE
Provider Other Middle Name:
LILLIAN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003254012
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
798 EXECUTIVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVIEDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32765-6392
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-359-8580
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
798 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVIEDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-359-8580
Provider Business Practice Location Address Fax Number:
407-359-8364
Provider Enumeration Date:
06/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  076953 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 35648 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: ME136423 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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