Healthcare Provider Details

I. General information

NPI: 1033630892
Provider Name (Legal Business Name): JESSICA ANNE TANG MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2017
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 BROCKTON AVE STE 103
RIVERSIDE CA
92506-0103
US

IV. Provider business mailing address

11234 ANDERSON ST RM 2586A
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2824
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMT213438
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberD93310
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberA199179
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberU4948
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: