Provider Demographics
NPI:1902950934
Name:DO, CHANH (DO)
Entity Type:Individual
Prefix:
First Name:CHANH
Middle Name:
Last Name:DO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WAWONA ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94127-1118
Mailing Address - Country:US
Mailing Address - Phone:708-466-6100
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-571-5880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036065498207P00000X
CA20A9226207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036065498Medicaid
IL098419OtherHEALTH ALLIANCE - KCH
IL100467OtherHEALTH ALLIANCE - VWCH
ILL99283Medicare PIN
IL100467OtherHEALTH ALLIANCE - VWCH
ILK11527Medicare UPIN
ILH56056Medicare UPIN