Healthcare Provider Details

I. General information

NPI: 1346303088
Provider Name (Legal Business Name): L TAN MD LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2006
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: 850-536-2460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME339964
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: L TAN
Title or Position: MGR
Credential:
Phone: 904-537-0954