Healthcare Provider Details

I. General information

NPI: 1235132762
Provider Name (Legal Business Name): L TAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2005
Last Update Date: 07/18/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 MADISON ST
MARIANNA FL
32446-3449
US

IV. Provider business mailing address

2915 MADISON ST
MARIANNA FL
32446-3449
US

V. Phone/Fax

Practice location:
  • Phone: 850-526-2460
  • Fax: 850-482-5450
Mailing address:
  • Phone: 850-526-2460
  • Fax: 850-303-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME33964
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberME33964
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: