Healthcare Provider Details

I. General information

NPI: 1457323222
Provider Name (Legal Business Name): GIM H TAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 12/08/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

813 N WASHINGTON AVE
ROSWELL NM
88201-3941
US

IV. Provider business mailing address

813 N WASHINGTON AVE
ROSWELL NM
88201-3941
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-2606
  • Fax: 575-622-6645
Mailing address:
  • Phone: 575-622-2606
  • Fax: 575-622-6645

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD2005-0011
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: