Healthcare Provider Details

I. General information

NPI: 1871756254
Provider Name (Legal Business Name): NELLY TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date: 02/07/2020
Reactivation Date: 04/09/2020

III. Provider practice location address

757 WESTOOD PLZ RRUMC 1621; MAILCODE: 743730
LOS ANGELES CA
90095-8358
US

IV. Provider business mailing address

757 WESTWOOD PLAZA RONALD REGAN UCLA MEDICAL CENTER
LOS ANGELES CA
90095
US

V. Phone/Fax

Practice location:
  • Phone: 310-957-9021
  • Fax:
Mailing address:
  • Phone: 310-267-8758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberME148615
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA114724
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number60018
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: