Healthcare Provider Details

I. General information

NPI: 1619974896
Provider Name (Legal Business Name): NELSON TAN CHAO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2005
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 CORPORATE DR SUITE 268
SHELTON CT
06484-6211
US

IV. Provider business mailing address

4 CORPORATE DR SUITE 268
SHELTON CT
06484-6211
US

V. Phone/Fax

Practice location:
  • Phone: 203-402-0377
  • Fax: 203-402-0772
Mailing address:
  • Phone: 203-402-0377
  • Fax: 203-402-0772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number032857
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number032857
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number032857
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: