Provider Demographics
NPI:1427023217
Name:TAN, BETHANY B (MD)
Entity Type:Individual
Prefix:
First Name:BETHANY
Middle Name:B
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 1:6251 E VIRGINIA BEACH BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2800
Mailing Address - Country:US
Mailing Address - Phone:757-261-5000
Mailing Address - Fax:757-962-5610
Practice Address - Street 1:6251 E VIRGINIA BEACH BLVD STE 300
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2800
Practice Address - Country:US
Practice Address - Phone:757-261-5000
Practice Address - Fax:757-962-5610
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD34085208600000X, 208G00000X
VA0101056108208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC010140897Medicaid
VA1427023217Medicaid
DC406906400Medicaid
DC036433200Medicaid
DCP00219340Medicare ID - Type UnspecifiedRAILROAD MEDICARE
DC010140897Medicaid
VA1427023217Medicare PIN
DC036433200Medicaid