Provider Demographics
NPI: | 1497813588 |
---|---|
Name: | TAN, STELLA (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | STELLA |
Middle Name: | |
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: | 224 E 2ND ST |
Mailing Address - Street 2: | |
Mailing Address - City: | DUMAS |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 79029-3808 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 806-934-7839 |
Mailing Address - Fax: | 806-934-7836 |
Practice Address - Street 1: | 224 E 2ND ST |
Practice Address - Street 2: | |
Practice Address - City: | DUMAS |
Practice Address - State: | TX |
Practice Address - Zip Code: | 79029-3808 |
Practice Address - Country: | US |
Practice Address - Phone: | 806-934-7839 |
Practice Address - Fax: | 806-934-7836 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-12-04 |
Last Update Date: | 2014-09-16 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | L6195 | 207L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 126264105 | Other | FIRSTCARE GROUP NUMBER |
TX | 855450 | Other | BCBS GROUP NUMBER |
TX | 096253203 | Medicaid | |
TX | 00593K | Medicare PIN | |
TX | 855450 | Other | BCBS GROUP NUMBER |
TX | P00289493 | Medicare ID - Type Unspecified | MEDICARE RAILROAD GROUP |