Healthcare Provider Details

I. General information

NPI: 1306077144
Provider Name (Legal Business Name): JOHN J K TAN MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2009
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 PARK ST
MONTCLAIR NJ
07042-2962
US

IV. Provider business mailing address

PO BOX 3405 MEMORIAL STATION
UPPER MONTCLAIR NJ
07043-3405
US

V. Phone/Fax

Practice location:
  • Phone: 973-746-4855
  • Fax: 973-746-5305
Mailing address:
  • Phone: 973-746-4855
  • Fax: 973-746-5305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number25MAO2451600
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN J K TAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-746-4855