Provider Demographics
NPI:1609227222
Name:TAN, CONNIE (OD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7637 HEATHERLY LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5602
Mailing Address - Country:US
Mailing Address - Phone:909-569-3780
Mailing Address - Fax:
Practice Address - Street 1:477 N EL CAMINO REAL STE C202
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1332
Practice Address - Country:US
Practice Address - Phone:760-631-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY08446152W00000X
CA33425152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist