Healthcare Provider Details

I. General information

NPI: 1568857365
Provider Name (Legal Business Name): TEDMAN LUCERO TAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 S MAIN RD
VINELAND NJ
08360-7828
US

IV. Provider business mailing address

150 S MAIN RD
VINELAND NJ
08360-7828
US

V. Phone/Fax

Practice location:
  • Phone: 856-691-2152
  • Fax: 856-696-3474
Mailing address:
  • Phone: 609-513-9150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00343900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: