Healthcare Provider Details

I. General information

NPI: 1639619703
Provider Name (Legal Business Name): MICHAEL TAN RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100296
GAINESVILLE FL
32610-0296
US

V. Phone/Fax

Practice location:
  • Phone: 352-265-0111
  • Fax:
Mailing address:
  • Phone: 352-627-9350
  • Fax: 352-273-9054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND8457
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4252
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: