Provider Demographics
NPI:1811001365
Name:TAN, SIMON S (MD)
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:S
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 1:731 E SOUTHLAKE BLVD STE 170
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6382
Mailing Address - Country:US
Mailing Address - Phone:817-488-0100
Mailing Address - Fax:817-488-4568
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:170
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-488-0100
Practice Address - Fax:817-488-4568
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL20232084N0008X, 2084N0600X, 2084P0301X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084P0301XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyBrain Injury MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151996901Medicaid
TX00527TMedicare ID - Type Unspecified
TX8118B6Medicare Oscar/Certification
TX151996901Medicaid