Provider Demographics
NPI:1245320001
Name:POLIDO, PHILLIP WILLIE TAN (MD)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WILLIE TAN
Last Name:POLIDO
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 1:2350 COUNTRY HILLS DR STE A
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-7436
Mailing Address - Country:US
Mailing Address - Phone:925-757-0800
Mailing Address - Fax:925-757-2160
Practice Address - Street 1:2350 COUNTRY HILLS DR STE A
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-7436
Practice Address - Country:US
Practice Address - Phone:925-757-0800
Practice Address - Fax:925-757-2160
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32794208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A327940Medicaid
CA020008734OtherMEDICARE RAILROAD
CA020008734OtherMEDICARE RAILROAD
CA00A327940Medicaid