Provider Demographics
NPI:1659662583
Name:TAN, GORDON (MD)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:
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 1:11175 CAMPUS ST
Mailing Address - Street 2:COLEMAN PAVILION A1111
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:909-558-4174
Mailing Address - Fax:909-558-4184
Practice Address - Street 1:11175 CAMPUS ST
Practice Address - Street 2:COLEMAN PAVILION A1111
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1700
Practice Address - Country:US
Practice Address - Phone:909-558-4174
Practice Address - Fax:909-558-4184
Is Sole Proprietor?:No
Enumeration Date:2011-04-26
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA122192208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics