Healthcare Provider Details

I. General information

NPI: 1962403097
Provider Name (Legal Business Name): CONCEPCION V TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2746 OCEAN AVE
BROOKLYN NY
11229
US

IV. Provider business mailing address

141 MIDWOOD ST
BROOKLYN NY
11225
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-8305
  • Fax: 718-332-2956
Mailing address:
  • Phone: 718-469-1717
  • Fax: 718-332-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number111610
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number111610
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: