Healthcare Provider Details

I. General information

NPI: 1912273384
Provider Name (Legal Business Name): ELAINE JUNE TAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 03/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2518 DOUGLASTON GLN
ESCONDIDO CA
92026-8550
US

IV. Provider business mailing address

2518 DOUGLASTON GLN
ESCONDIDO CA
92026-8550
US

V. Phone/Fax

Practice location:
  • Phone: 760-839-2815
  • Fax:
Mailing address:
  • Phone: 760-839-2815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14378
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: