Provider Demographics
NPI:1134277569
Name:TAN, ANTONIO A (MD)
Entity type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:A
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 1:12980 FREDERICK ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5263
Mailing Address - Country:US
Mailing Address - Phone:951-485-2744
Mailing Address - Fax:
Practice Address - Street 1:12980 FREDERICK ST
Practice Address - Street 2:SUITE D
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5263
Practice Address - Country:US
Practice Address - Phone:951-485-2744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45416207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A454161Medicaid
CA00A454161Medicaid
CA00A454160Medicare ID - Type UnspecifiedMEDICARE