Provider Demographics
NPI:1457323222
Name:TAN, GIM H (MD)
Entity Type:Individual
Prefix:
First Name:GIM
Middle Name:H
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 1:813 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3941
Mailing Address - Country:US
Mailing Address - Phone:575-622-2606
Mailing Address - Fax:575-622-6645
Practice Address - Street 1:813 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3941
Practice Address - Country:US
Practice Address - Phone:575-622-2606
Practice Address - Fax:575-622-6645
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM8026564Medicaid
NM8026564Medicaid
NM346619401Medicare PIN