Healthcare Provider Details

I. General information

NPI: 1437456225
Provider Name (Legal Business Name): SALLY Q TAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 N CLASSEN BLVD SUITE 204
OKLAHOMA CITY OK
73106-6843
US

IV. Provider business mailing address

1110 N CLASSEN BLVD SUITE 204
OKLAHOMA CITY OK
73106-6843
US

V. Phone/Fax

Practice location:
  • Phone: 405-319-1622
  • Fax: 405-319-1575
Mailing address:
  • Phone: 405-319-1622
  • Fax: 405-319-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number19992
License Number StateOK

VIII. Authorized Official

Name: DR. SALLY Q. TAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 405-319-1622