Provider Demographics
NPI:1639619703
Name:TAN, MICHAEL (RD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:RD
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 100325
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0325
Mailing Address - Country:US
Mailing Address - Phone:352-265-0111
Mailing Address - Fax:352-265-1071
Practice Address - Street 1:LAHEY HOSPITAL AND MEDICAL CTR
Practice Address - Street 2:41 MALL ROAD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-0001
Practice Address - Country:US
Practice Address - Phone:781-744-8944
Practice Address - Fax:781-744-2581
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8457133V00000X
MA4252133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered