Provider Demographics
NPI:1659433654
Name:TAN, ERNESTO C (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:C
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 1:4373 BRIDGETOWN RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-4427
Mailing Address - Country:US
Mailing Address - Phone:513-598-8858
Mailing Address - Fax:513-598-8861
Practice Address - Street 1:4373 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-4427
Practice Address - Country:US
Practice Address - Phone:513-598-8858
Practice Address - Fax:513-598-8861
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-7940-T207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0503173Medicaid
OHA80742Medicare UPIN
OH0539415Medicare ID - Type Unspecified