Provider Demographics
NPI:1902847197
Name:TAN, VIVIAN C
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:C
Last Name:TAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:462 GRIDER ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215-3021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY21148012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000525320003OtherBLUE SHIELD OF WESTERN NY
300122828OtherRAILROAD MEDICARE
NY01876553Medicaid
5610372OtherINDEPENDANT HEALTH
00025568101OtherUNIVERA
NY2114809WOtherWORKERS COMPENSATION
140848FFOtherPREFERRED CARE
300122828OtherRAILROAD MEDICARE
140848FFOtherPREFERRED CARE