Healthcare Provider Details

I. General information

NPI: 1316149214
Provider Name (Legal Business Name): TERESA X TAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2007
Last Update Date: 12/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 OMNI BLVD SUITE 101
NEWPORT NEWS VA
23606
US

IV. Provider business mailing address

860 OMNI BLVD STE 101
NEWPORT NEWS VA
23606-4430
US

V. Phone/Fax

Practice location:
  • Phone: 757-223-9794
  • Fax: 757-223-9168
Mailing address:
  • Phone: 757-232-8777
  • Fax: 757-232-8866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number0116017793
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: