Provider Demographics
NPI:1700869229
Name:TAN, RAYMUNDO T (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMUNDO
Middle Name:T
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 1:419 5TH ST NE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-3300
Mailing Address - Country:US
Mailing Address - Phone:701-252-1050
Mailing Address - Fax:701-952-3265
Practice Address - Street 1:419 5TH ST NE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-3300
Practice Address - Country:US
Practice Address - Phone:701-252-1050
Practice Address - Fax:701-952-3265
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND46692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND18514Medicaid
01008891OtherPREFERRED ONE
16-11656OtherMEDICA
SD7207820Medicaid
47607OtherHEALTHPARTNERS
ND13243OtherBLUE SHIELD
46031641458401C003OtherTRICARE
719609OtherAMERICA'S PPO
ND13243OtherBLUE SHIELD
01008891OtherPREFERRED ONE