Provider Demographics
NPI:1437456225
Name:SALLY Q TAN MD PC
Entity Type:Organization
Organization Name:SALLY Q TAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:Q
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-319-1622
Mailing Address - Street 1:1110 N CLASSEN BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6843
Mailing Address - Country:US
Mailing Address - Phone:405-319-1622
Mailing Address - Fax:405-319-1575
Practice Address - Street 1:1110 N CLASSEN BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6843
Practice Address - Country:US
Practice Address - Phone:405-319-1622
Practice Address - Fax:405-319-1575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19992261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty