Provider Demographics
NPI:1891745360
Name:TAN, LUIS Y (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:Y
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 1:762 EASTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44305
Mailing Address - Country:US
Mailing Address - Phone:330-794-1279
Mailing Address - Fax:330-794-1902
Practice Address - Street 1:762 EASTLAND AVE
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44305
Practice Address - Country:US
Practice Address - Phone:330-794-1279
Practice Address - Fax:330-794-1902
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2015-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35034421208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0209643Medicaid
OH0209643Medicaid
TA0371631Medicare ID - Type Unspecified