Provider Demographics
NPI:1598149213
Name:LU, MARIE KATRINA TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE KATRINA
Middle Name:TAN
Last Name:LU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARIE KATRINA
Other - Middle Name:LEONIN
Other - Last Name:TAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1046 RIDGE AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-1640
Practice Address - Country:US
Practice Address - Phone:404-688-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-13
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT209530390200000X
GA081623208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program