Provider Demographics
NPI:1083771489
Name:TAN, YONG (MD)
Entity Type:Individual
Prefix:
First Name:YONG
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:516 WEST ATEN ROAD, SUITE 2
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251
Mailing Address - Country:US
Mailing Address - Phone:760-355-7730
Mailing Address - Fax:760-355-7731
Practice Address - Street 1:751 WEST LEGION ROAD, SUITE 102
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227
Practice Address - Country:US
Practice Address - Phone:760-351-8696
Practice Address - Fax:760-545-0253
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55855207Q00000X
CAA055855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW13536AOtherMEDICARE GROUP
CAW13536DOtherMEDICARE GROUP #
CAW13536COtherMEDICARE GROUP #
CAW13536BOtherMEDIARE GROUP #
CAGR0066310OtherMEDI-CAL GROUP
CAGB975TMedicare PIN
CAW13536DOtherMEDICARE GROUP #
CAW13536AOtherMEDICARE GROUP