Healthcare Provider Details

I. General information

NPI: 1699942425
Provider Name (Legal Business Name): IRENE S. TAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 06/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 RED TAIL WAY
SIMI VALLEY CA
93065-7232
US

IV. Provider business mailing address

1147 RED TAIL WAY
SIMI VALLEY CA
93065-7232
US

V. Phone/Fax

Practice location:
  • Phone: 805-527-8055
  • Fax: 805-520-8849
Mailing address:
  • Phone: 805-527-8055
  • Fax: 805-520-8849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberPENDING
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: