Provider Demographics
NPI:1245208420
Name:TAN, MABLE (MD)
Entity Type:Individual
Prefix:
First Name:MABLE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 SOUTHPOINT DR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-8007
Mailing Address - Country:US
Mailing Address - Phone:904-470-6900
Mailing Address - Fax:904-470-6901
Practice Address - Street 1:6900 SOUTHPOINT DR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-8007
Practice Address - Country:US
Practice Address - Phone:904-470-6900
Practice Address - Fax:904-470-6901
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME95051207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G57611Medicare UPIN