Healthcare Provider Details

I. General information

NPI: 1154305639
Provider Name (Legal Business Name): RICKY POKBOON TANG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

IV. Provider business mailing address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-3689
  • Fax: 951-784-3271
Mailing address:
  • Phone: 951-782-3689
  • Fax: 951-784-3271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA70284
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: