Healthcare Provider Details

I. General information

NPI: 1295758126
Provider Name (Legal Business Name): MATTHEW S TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 E CESAR E CHAVEZ AVE SUITE 300
LOS ANGELES CA
90033-2464
US

IV. Provider business mailing address

1701 E CESAR E CHAVEZ AVE SUITE 300
LOS ANGELES CA
90033-2464
US

V. Phone/Fax

Practice location:
  • Phone: 323-264-2633
  • Fax: 323-224-2790
Mailing address:
  • Phone: 323-264-2633
  • Fax: 323-224-2790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG19327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: