Provider Demographics
NPI:1285630202
Name:TAN, JESSE WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:WILLIAM
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:2865 ATLANTIC AVE
Mailing Address - Street 2:STE 225
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-7428
Mailing Address - Country:US
Mailing Address - Phone:562-988-8818
Mailing Address - Fax:562-988-8819
Practice Address - Street 1:2865 ATLANTIC AVE
Practice Address - Street 2:STE 225
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-7428
Practice Address - Country:US
Practice Address - Phone:562-988-8818
Practice Address - Fax:562-988-8819
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2010-12-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA068881207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H87392Medicare ID - Type Unspecified