Provider Demographics
NPI:1639167547
Name:TAN, ALFRED W (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:W
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 1:1804 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1804 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:LEVELLAND
Practice Address - State:TX
Practice Address - Zip Code:79336-6507
Practice Address - Country:US
Practice Address - Phone:806-894-3141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE3782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
2278730OtherFIRSTHEALTH
5915336OtherAETNA
TX00JB67OtherBLUECROSS/BLUESHIELD
TX119655OtherSUPERIOR HEALTH PLAN
5585877OtherCCN
TX00JB67OtherBLUECROSS/BLUESHIELD
5585877OtherCCN