Provider Demographics
NPI:1851384044
Name:TAN, DE
Entity Type:Individual
Prefix:
First Name:DE
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:2725 CAPITOL AVE DEPT 300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-6006
Practice Address - Country:US
Practice Address - Phone:916-262-9370
Practice Address - Fax:916-262-9375
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90989207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A909890Medicaid
CAZZZ80876ZMedicaid
CAZZZ80876ZMedicaid
CAI29296Medicare UPIN
CAA90989Medicare PIN