Provider Demographics
NPI:1003179433
Name:TAN, PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14467 26TH AVE
Mailing Address - Street 2:1ST FL
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-1326
Mailing Address - Country:US
Mailing Address - Phone:917-215-0782
Mailing Address - Fax:
Practice Address - Street 1:14467 26TH AVE
Practice Address - Street 2:1ST FL
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-1326
Practice Address - Country:US
Practice Address - Phone:917-215-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY56 007878152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist