Provider Demographics
NPI:1093795395
Name:TAN, JOHN U (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:U
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-825-2229
Mailing Address - Fax:765-825-9767
Practice Address - Street 1:1473 E STATE ROAD 44
Practice Address - Street 2:SUITE 3
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-8374
Practice Address - Country:US
Practice Address - Phone:765-825-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-20
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042239A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200129020Medicaid
IN000000705820OtherANTHEM
INH61757Medicare UPIN
INM400044629Medicare PIN