Healthcare Provider Details

I. General information

NPI: 1053657684
Provider Name (Legal Business Name): MAYBEL MIN TAN M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2012
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3114 W BEVERLY BLVD
MONTEBELLO CA
90640-2217
US

IV. Provider business mailing address

2149 E WARNER RD STE 102
TEMPE AZ
85284-3495
US

V. Phone/Fax

Practice location:
  • Phone: 323-726-3868
  • Fax:
Mailing address:
  • Phone: 480-393-0309
  • Fax: 480-610-6189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA126350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: