Healthcare Provider Details

I. General information

NPI: 1629385927
Provider Name (Legal Business Name): JUSTIN HONG-JIE TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2010
Last Update Date: 12/01/2021
Certification Date: 12/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE DEPARTMENT OF RADIOLOGY
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

4647 ZION AVE DEPARTMENT OF RADIOLOGY
SAN DIEGO CA
92120-2507
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-6000
  • Fax:
Mailing address:
  • Phone: 619-528-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA113634
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA113634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: