Provider Demographics
NPI:1093883340
Name:TAN, IMELDA CASTILLO (OD)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:CASTILLO
Last Name:TAN
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:7901 ROCKWELL AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-2222
Mailing Address - Country:US
Mailing Address - Phone:215-342-0392
Mailing Address - Fax:215-739-3661
Practice Address - Street 1:3166 KENSINGTON AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19134-2421
Practice Address - Country:US
Practice Address - Phone:215-425-3937
Practice Address - Fax:215-739-3661
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-02
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOEG000945152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist