Provider Demographics
NPI:1083770580
Name:TAN, MARK (MD)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:222 MIDDLE COUNTRY ROAD
Mailing Address - Street 2:SUITE 312
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787
Mailing Address - Country:US
Mailing Address - Phone:631-724-8900
Mailing Address - Fax:631-724-8901
Practice Address - Street 1:222 MIDDLE COUNTRY ROAD
Practice Address - Street 2:SUITE 312
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787
Practice Address - Country:US
Practice Address - Phone:631-724-8900
Practice Address - Fax:631-724-8901
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2011-07-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY165674207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986705Medicaid
NY00986705Medicaid
59H071Medicare ID - Type Unspecified