Provider Demographics
NPI:1114309051
Name:TAN, WENNY (OD)
Entity Type:Individual
Prefix:
First Name:WENNY
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 CHARLES PLZ APT 405
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-4202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1505 ANNAPOLIS MALL
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3090
Practice Address - Country:US
Practice Address - Phone:410-573-2095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-28
Last Update Date:2015-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2469152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist