Provider Demographics
NPI:1316185820
Name:TANDON, BEVAN (MD)
Entity Type:Individual
Prefix:
First Name:BEVAN
Middle Name:
Last Name:TANDON
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 1:4251 RUSSELL BLVD APT A
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-3510
Mailing Address - Country:US
Mailing Address - Phone:757-395-7609
Mailing Address - Fax:
Practice Address - Street 1:303 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4296
Practice Address - Country:US
Practice Address - Phone:312-503-8223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014018834291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory