Healthcare Provider Details

I. General information

NPI: 1811130743
Provider Name (Legal Business Name): ERIC WAN TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 11/27/2023
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 SAN PABLO ST SUITE 2000
LOS ANGELES CA
90033-5310
US

IV. Provider business mailing address

PO BOX 31309
LOS ANGELES CA
90031-0309
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-5860
  • Fax:
Mailing address:
  • Phone: 323-442-5860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberA136124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: