Provider Demographics
NPI:1790742047
Name:TAN, BERNARDO O JR (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNARDO
Middle Name:O
Last Name:TAN
Suffix:JR
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 1:9305 W THOMAS RD
Mailing Address - Street 2:SUITE 410
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-3328
Mailing Address - Country:US
Mailing Address - Phone:623-322-8478
Mailing Address - Fax:623-322-8430
Practice Address - Street 1:9305 W THOMAS RD
Practice Address - Street 2:SUITE #410
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-3328
Practice Address - Country:US
Practice Address - Phone:623-322-8478
Practice Address - Fax:623-322-8430
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ946923-01Medicaid
AZ946923-01Medicaid
AZZ104298Medicare PIN