Healthcare Provider Details

I. General information

NPI: 1730185687
Provider Name (Legal Business Name): JESUS KING TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2005
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 ATLANTIC AVE STE 225
LONG BEACH CA
90806-7428
US

IV. Provider business mailing address

2865 ATLANTIC AVE STE 225
LONG BEACH CA
90806-7428
US

V. Phone/Fax

Practice location:
  • Phone: 562-988-8818
  • Fax: 562-988-8819
Mailing address:
  • Phone: 562-988-8818
  • Fax: 562-988-8819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA31335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: