Provider Demographics
NPI:1598870248
Name:TAN, CATHERINE (MD)
Entity Type:Individual
Prefix:
First Name:CATHERINE
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 1:1454 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92408-0118
Mailing Address - Country:US
Mailing Address - Phone:909-382-7146
Mailing Address - Fax:
Practice Address - Street 1:1454 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0118
Practice Address - Country:US
Practice Address - Phone:909-382-7146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78137208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G781370Medicaid
G25277Medicare UPIN
00G781370Medicare ID - Type Unspecified