Provider Demographics
NPI:1235132762
Name:TAN, L (MD)
Entity Type:Individual
Prefix:
First Name:L
Middle Name:
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 1:2915 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3449
Mailing Address - Country:US
Mailing Address - Phone:850-526-2460
Mailing Address - Fax:850-482-5450
Practice Address - Street 1:2915 MADISON ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3449
Practice Address - Country:US
Practice Address - Phone:850-526-2460
Practice Address - Fax:850-482-5450
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-30
Last Update Date:2015-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME33964208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL123513762OtherNPI