Provider Demographics
NPI:1679525349
Name:TAN, LUCAS GO (MD)
Entity Type:Individual
Prefix:
First Name:LUCAS
Middle Name:GO
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 1:10165 DOUGHERTY AVE
Mailing Address - Street 2:
Mailing Address - City:MORGAN HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95037
Mailing Address - Country:US
Mailing Address - Phone:408-778-2417
Mailing Address - Fax:
Practice Address - Street 1:989 STORY RD
Practice Address - Street 2:UNIT 8063
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-4620
Practice Address - Country:US
Practice Address - Phone:408-259-5000
Practice Address - Fax:408-928-7041
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA25847207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A258470Medicaid
A24601Medicare UPIN
CA00A258470Medicare ID - Type Unspecified