Provider Demographics
NPI:1104825785
Name:TAN, CHUN WANG Y (MD)
Entity Type:Individual
Prefix:
First Name:CHUN WANG
Middle Name:Y
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 1:1808 HIGHWAY 97 E
Mailing Address - Street 2:
Mailing Address - City:JOURDANTON
Mailing Address - State:TX
Mailing Address - Zip Code:78026-1535
Mailing Address - Country:US
Mailing Address - Phone:830-569-4003
Mailing Address - Fax:830-569-4001
Practice Address - Street 1:1808 HIGHWAY 97 E
Practice Address - Street 2:
Practice Address - City:JOURDANTON
Practice Address - State:TX
Practice Address - Zip Code:78026-1535
Practice Address - Country:US
Practice Address - Phone:830-569-4003
Practice Address - Fax:830-569-4001
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK3862207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037007401Medicaid
TX8028M0OtherBCBS
TX8G9388OtherBCBS
TX037007403Medicaid
G61387Medicare UPIN
TX8K2308Medicare PIN
TX8028M0Medicare PIN