Provider Demographics
NPI:1003807868
Name:ESTAMPADOR TAN, JOSEPHINE RACIMO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPHINE
Middle Name:RACIMO
Last Name:ESTAMPADOR TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4405
Mailing Address - Country:US
Mailing Address - Phone:407-931-1887
Mailing Address - Fax:407-931-2056
Practice Address - Street 1:1125 N CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4405
Practice Address - Country:US
Practice Address - Phone:407-931-1887
Practice Address - Fax:407-931-2056
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 60270174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1290808OtherCIGNA PROVIDER ID #
FL270637OtherAVMED PROVIDER ID #
FL14049OtherBCBS PROVIDER ID #
FL173108OtherWELLCARE PROVIDER ID #
FL371692900Medicaid
FL371692900Medicaid