Healthcare Provider Details

I. General information

NPI: 1679525349
Provider Name (Legal Business Name): LUCAS GO TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

989 STORY RD UNIT 8063
SAN JOSE CA
95122-4620
US

IV. Provider business mailing address

10165 DOUGHERTY AVE
MORGAN HILL CA
95037
US

V. Phone/Fax

Practice location:
  • Phone: 408-259-5000
  • Fax: 408-928-7041
Mailing address:
  • Phone: 408-778-2417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA25847
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: