Healthcare Provider Details

I. General information

NPI: 1316948391
Provider Name (Legal Business Name): CORNELIA W. TAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E OVERTON RD
DALLAS TX
75216-5946
US

IV. Provider business mailing address

PO BOX 660599
DALLAS TX
75266-0599
US

V. Phone/Fax

Practice location:
  • Phone: 214-266-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberJ2363
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: