MEDICARE: DE TAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	A90989	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851384044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DE TAN

Provider Business Mailing Address
First Line	:	10470 OLD PLACERVILLE RD STE 100
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95827-2539
Country	:	US
Telephone Number	:	800-470-0071
Fax Number	:

Provider Business Practice Location Address
First Line	:	2725 CAPITOL AVE DEPT 300
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95816-6006
Country	:	US
Telephone Number	:	916-262-9370
Fax Number	:	916-262-9375

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	12/20/2018

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Directions to “ DE TAN ” Practice Location

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