Provider Demographics
NPI:1124387626
Name:TAN, JEREMY F (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:F
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 1:608 STANTON L YOUNG BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73104-5065
Mailing Address - Country:US
Mailing Address - Phone:405-271-6060
Mailing Address - Fax:405-271-3013
Practice Address - Street 1:608 STANTON L YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-271-6060
Practice Address - Fax:405-271-3013
Is Sole Proprietor?:No
Enumeration Date:2012-05-04
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK29985207W00000X, 207WX0200X
PAMT201060390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0200XAllopathic & Osteopathic PhysiciansOphthalmologyOphthalmic Plastic and Reconstructive Surgery
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200504570BMedicaid