Provider Demographics
NPI:1013099746
Name:TAN, KWAN TOH (MD)
Entity Type:Individual
Prefix:DR
First Name:KWAN
Middle Name:TOH
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 1:13561 YORBA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-1869
Mailing Address - Country:US
Mailing Address - Phone:714-527-8943
Mailing Address - Fax:714-527-9086
Practice Address - Street 1:7872 WALKER ST
Practice Address - Street 2:
Practice Address - City:LA PALMA
Practice Address - State:CA
Practice Address - Zip Code:90623-1796
Practice Address - Country:US
Practice Address - Phone:714-527-8777
Practice Address - Fax:714-527-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74232207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G742320Medicaid
CAGR0061200Medicaid
CAGR0061190Medicaid
CA00G742320Medicaid
CAE97502Medicare UPIN
CAW12122AMedicare ID - Type UnspecifiedMEDICARE GROUP # BP
CA5297826Medicare UPIN
CAWG74232CMedicare ID - Type UnspecifiedPPIN CERRITOS OFFICE
CAWG74232AMedicare ID - Type UnspecifiedPPIN BUENA PARK OFFICE
CAGR0061200Medicaid