Provider Demographics
NPI:1417957697
Name:TAN, LORENA H (MD)
Entity Type:Individual
Prefix:DR
First Name:LORENA
Middle Name:H
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 E STANLEY BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94550-4200
Mailing Address - Country:US
Mailing Address - Phone:925-443-9000
Mailing Address - Fax:925-443-9009
Practice Address - Street 1:1133 E STANLEY BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:LIVERMORE
Practice Address - State:CA
Practice Address - Zip Code:94550-4200
Practice Address - Country:US
Practice Address - Phone:925-443-9000
Practice Address - Fax:925-443-9009
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A613520Medicaid
G83156Medicare UPIN
CA00A613520Medicare ID - Type Unspecified