Provider Demographics
NPI:1184667289
Name:TAN, KONG (MD)
Entity type:Individual
Prefix:
First Name:KONG
Middle Name:
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:PO BOX 60280
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29419-0280
Mailing Address - Country:US
Mailing Address - Phone:732-739-5847
Mailing Address - Fax:
Practice Address - Street 1:727 N BEERS ST
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1514
Practice Address - Country:US
Practice Address - Phone:732-739-5847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03121400174400000X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0152871Medicaid
NJ2406192000OtherAMERIHEALTH #
NJ221494442OtherTAX ID#
NJ60014873OtherHORIZON NJ HEALTH #
NJP3617811OtherOXFORD #
NJP00247907OtherRR MDCR #
NJXK5557OtherHEALTHNET #
NJ55628XJXMedicare PIN
NJ221494442OtherTAX ID#
NJP00247907OtherRR MDCR #