Healthcare Provider Details

I. General information

NPI: 1104824630
Provider Name (Legal Business Name): VIRGINIA M TJAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 5TH ST
MONTROSE CO
81401-5711
US

IV. Provider business mailing address

600 S 5TH ST
MONTROSE CO
81401-5711
US

V. Phone/Fax

Practice location:
  • Phone: 970-497-8001
  • Fax: 970-240-7793
Mailing address:
  • Phone: 970-497-8001
  • Fax: 970-240-7793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number036026
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number47519
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: