Provider Demographics
NPI:1104862838
Name:QUE, EMERSON TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EMERSON
Middle Name:TAN
Last Name:QUE
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 1:527 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-9010
Mailing Address - Country:US
Mailing Address - Phone:681-342-3500
Mailing Address - Fax:681-342-3507
Practice Address - Street 1:211 S CHESTNUT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2832
Practice Address - Country:US
Practice Address - Phone:304-624-5212
Practice Address - Fax:304-623-5812
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0067034173000000X
DEC1-0008687173000000X
WV26518207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD414437600Medicaid
MD174LS816Medicare PIN
DE134280ZA6JMedicare PIN
I51272Medicare UPIN