Provider Demographics
NPI:1952659203
Name:ZHAO, TAILUN (MD)
Entity Type:Individual
Prefix:
First Name:TAILUN
Middle Name:
Last Name:ZHAO
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 1:450 FLETCHER PKWY STE 112
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2520
Mailing Address - Country:US
Mailing Address - Phone:800-898-2020
Mailing Address - Fax:626-577-2100
Practice Address - Street 1:450 FLETCHER PKWY STE 112
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2520
Practice Address - Country:US
Practice Address - Phone:800-898-2020
Practice Address - Fax:844-897-3788
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-16
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26997207W00000X
PAMD457911207W00000X
390200000X
CAC186414207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA508247EVXMedicare PIN