Healthcare Provider Details

I. General information

NPI: 1659662583
Provider Name (Legal Business Name): GORDON TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 11/30/2024
Certification Date: 11/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12815 HEACOCK ST
MORENO VALLEY CA
92553-2836
US

IV. Provider business mailing address

12815 HEACOCK ST
MORENO VALLEY CA
92553-2836
US

V. Phone/Fax

Practice location:
  • Phone: 951-601-6399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA122192
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: