Provider Demographics
NPI:1396835633
Name:TAN, TERESITA EGIDO (MD)
Entity Type:Individual
Prefix:MRS
First Name:TERESITA
Middle Name:EGIDO
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:244 S OXFORD AVE
Mailing Address - Street 2:#9
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-5173
Mailing Address - Country:US
Mailing Address - Phone:213-382-1770
Mailing Address - Fax:213-382-1895
Practice Address - Street 1:244 S OXFORD AVE
Practice Address - Street 2:#9
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004
Practice Address - Country:US
Practice Address - Phone:213-382-1770
Practice Address - Fax:213-382-1895
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2010-12-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA40376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A403760Medicaid
CA00A403760Medicaid
CAA85447Medicare UPIN