Provider Demographics
NPI:1407085210
Name:TAN, ALFONSO OLIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:OLIVA
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:PO BOX 534
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:OR
Mailing Address - Zip Code:97495-0534
Mailing Address - Country:US
Mailing Address - Phone:541-673-4516
Mailing Address - Fax:
Practice Address - Street 1:305 THORA CIRCLE DR.
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:OR
Practice Address - Zip Code:97495
Practice Address - Country:US
Practice Address - Phone:541-673-4516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2009-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD13317207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine