Healthcare Provider Details

I. General information

NPI: 1083771489
Provider Name (Legal Business Name): YONG TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 WEST LEGION ROAD, SUITE 102
BRAWLEY CA
92227
US

IV. Provider business mailing address

516 WEST ATEN ROAD, SUITE 2
IMPERIAL CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-351-8696
  • Fax: 760-545-0253
Mailing address:
  • Phone: 760-355-7730
  • Fax: 760-355-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA55855
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA055855
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: