Healthcare Provider Details

I. General information

NPI: 1437300597
Provider Name (Legal Business Name): BENNY KIEN HON TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2646 E. BANNER GATEWAY DRRIVE
GILBERT AZ
85234-2165
US

IV. Provider business mailing address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-6444
  • Fax: 480-256-4734
Mailing address:
  • Phone: 904-383-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License NumberME94940
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME94940
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: