Healthcare Provider Details

I. General information

NPI: 1396715769
Provider Name (Legal Business Name): JESUS HO TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 11/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 S BROADWAY
FROSTBURG MD
21532-1708
US

IV. Provider business mailing address

4 S BROADWAY
FROSTBURG MD
21532-1708
US

V. Phone/Fax

Practice location:
  • Phone: 301-689-3138
  • Fax: 301-689-9561
Mailing address:
  • Phone: 301-689-3138
  • Fax: 301-689-9561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number521167179
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: