Healthcare Provider Details

I. General information

NPI: 1790742047
Provider Name (Legal Business Name): BERNARDO O TAN JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 01/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 W THOMAS RD SUITE #410
PHOENIX AZ
85037-3328
US

IV. Provider business mailing address

9305 W THOMAS RD SUITE 410
PHOENIX AZ
85037-3328
US

V. Phone/Fax

Practice location:
  • Phone: 623-322-8478
  • Fax: 623-322-8430
Mailing address:
  • Phone: 623-322-8478
  • Fax: 623-322-8430

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: