Provider Demographics
NPI:1922390657
Name:CONNIE T TAN, M D A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CONNIE T TAN, M D A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:TENG
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-988-7688
Mailing Address - Street 1:2485 HOSPITAL DR
Mailing Address - Street 2:SUITE 251
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-4101
Mailing Address - Country:US
Mailing Address - Phone:650-988-7688
Mailing Address - Fax:650-988-7638
Practice Address - Street 1:2485 HOSPITAL DR
Practice Address - Street 2:SUITE 251
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-4101
Practice Address - Country:US
Practice Address - Phone:650-988-7688
Practice Address - Fax:650-988-7638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG634870207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G634870Medicare UPIN