Provider Demographics
NPI:1134271232
Name:TAN, BRENT THOMAS (MD, PHD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:THOMAS
Last Name:TAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 PASTEUR DR DEPT OF
Mailing Address - Street 2:
Mailing Address - City:STANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:94305-2200
Mailing Address - Country:US
Mailing Address - Phone:650-723-7211
Mailing Address - Fax:650-725-7409
Practice Address - Street 1:300 PASTEUR DR RM L235
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:STANFORD
Practice Address - State:CA
Practice Address - Zip Code:94305-2200
Practice Address - Country:US
Practice Address - Phone:650-723-7211
Practice Address - Fax:650-725-7409
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86418207ZC0008X, 207ZH0000X, 207ZP0102X, 207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZC0008XAllopathic & Osteopathic PhysiciansPathologyClinical Informatics
No207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A864180Medicaid
CA00A864180Medicare ID - Type Unspecified
CAI29945Medicare UPIN