Provider Demographics
NPI:1306008834
Name:TAN, KENNETH TAN (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:TAN
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3455 S NOGALES ST
Mailing Address - Street 2:STE 140
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-5104
Mailing Address - Country:US
Mailing Address - Phone:626-861-3131
Mailing Address - Fax:
Practice Address - Street 1:5820 OBERLIN DR
Practice Address - Street 2:STE. 205
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3742
Practice Address - Country:US
Practice Address - Phone:877-570-8362
Practice Address - Fax:877-570-8362
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2020-12-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GUM-20192085R0202X
TXJ62622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology