Provider Demographics
NPI:1215033972
Name:TANNAN, DILIP KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:DILIP
Middle Name:KUMAR
Last Name:TANNAN
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 1:555 S WASHBURN ST
Mailing Address - Street 2:CTE 2
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-6710
Mailing Address - Country:US
Mailing Address - Phone:920-231-2555
Mailing Address - Fax:920-236-3248
Practice Address - Street 1:555 S WASHBURN ST
Practice Address - Street 2:CTE 2
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-6710
Practice Address - Country:US
Practice Address - Phone:920-231-2555
Practice Address - Fax:920-236-3248
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI26504207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30731900Medicaid
WI000071139Medicare ID - Type Unspecified
WI30731900Medicaid