Provider Demographics
NPI:1629149901
Name:TAN, JOSEPH SON (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:SON
Last Name:TAN
Suffix:
Gender:M
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:PO BOX 4929
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-4929
Mailing Address - Country:US
Mailing Address - Phone:562-404-0503
Mailing Address - Fax:562-529-8828
Practice Address - Street 1:16660 PARAMOUNT BLVD
Practice Address - Street 2:#312
Practice Address - City:PARAMOUNT
Practice Address - State:CA
Practice Address - Zip Code:90723-5433
Practice Address - Country:US
Practice Address - Phone:562-404-0503
Practice Address - Fax:562-529-8828
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40103207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A401031Medicaid
CA00A401031Medicaid
A 29047Medicare UPIN