Provider Demographics
NPI:1962475533
Name:TAN, EDISON N (MD)
Entity Type:Individual
Prefix:
First Name:EDISON
Middle Name:N
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 1:1840 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33755-2138
Mailing Address - Country:US
Mailing Address - Phone:727-442-3001
Mailing Address - Fax:727-467-9106
Practice Address - Street 1:1840 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33755-2138
Practice Address - Country:US
Practice Address - Phone:727-442-3001
Practice Address - Fax:727-467-9106
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78501207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
49390OtherBLUE CROSS
G96108Medicare UPIN
GAE2684XMedicare PIN