Healthcare Provider Details

I. General information

NPI: 1881082683
Provider Name (Legal Business Name): RICARDO ANTONIO TAN MD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2014
Last Update Date: 12/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5219 CEDROS AVE
SHERMAN OAKS CA
91411-4016
US

IV. Provider business mailing address

5219 CEDROS AVE
SHERMAN OAKS CA
91411-4016
US

V. Phone/Fax

Practice location:
  • Phone: 310-709-2693
  • Fax:
Mailing address:
  • Phone: 310-709-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0201X
TaxonomyAllergy & Immunology (Internal Medicine) Physician
License NumberA52236
License Number StateCA

VIII. Authorized Official

Name: DR. RICARDP ANTONIO TAN
Title or Position: OWNER
Credential: M.D.
Phone: 310-709-2693