Provider Demographics
NPI:1346260429
Name:TAN, ENRICO (DPM)
Entity Type:Individual
Prefix:DR
First Name:ENRICO
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1819
Mailing Address - Country:US
Mailing Address - Phone:740-592-2366
Mailing Address - Fax:740-594-2871
Practice Address - Street 1:410 E STATE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1819
Practice Address - Country:US
Practice Address - Phone:740-592-2366
Practice Address - Fax:740-594-2871
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002613213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0765159Medicaid
OH000000123607OtherANTHEM BC/BS PROV NUMBER
OH0784560001OtherDMERC
OHT90000Medicare UPIN
OHTA0654443Medicare PIN