Provider Demographics
NPI:1851658173
Name:VANICHSARN, CHRISTOPHER TAN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:TAN
Last Name:VANICHSARN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-9100
Mailing Address - Fax:
Practice Address - Street 1:1955 CITRACADO PKWY STE 300
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92029-4113
Practice Address - Country:US
Practice Address - Phone:760-743-0546
Practice Address - Fax:858-673-5187
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA129210207R00000X, 207RC0000X, 208M00000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA129210OtherCA MEDICAL LICENSE