Provider Demographics
NPI:1295826519
Name:TAN, ALFONSO A (MD)
Entity Type:Individual
Prefix:MR
First Name:ALFONSO
Middle Name:A
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 1:6242 E ARBOR AVE # 111-113
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1309
Mailing Address - Country:US
Mailing Address - Phone:480-536-6863
Mailing Address - Fax:480-718-1301
Practice Address - Street 1:6242 E ARBOR AVE # 111-113
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1309
Practice Address - Country:US
Practice Address - Phone:480-536-6863
Practice Address - Fax:480-718-1301
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ22583207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F85979Medicare UPIN
AZZ28281Medicare ID - Type Unspecified