Provider Demographics
NPI:1609888429
Name:TJAN, STEPHANUS JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANUS
Middle Name:JOSEPH
Last Name:TJAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:191 E ORCHARD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80121-8057
Mailing Address - Country:US
Mailing Address - Phone:303-459-2150
Mailing Address - Fax:855-751-4155
Practice Address - Street 1:191 E ORCHARD RD STE 203
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80121-8057
Practice Address - Country:US
Practice Address - Phone:303-459-2150
Practice Address - Fax:855-751-4155
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO49802207R00000X
NY130863207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO72181281Medicaid
CO72181281Medicaid