Provider Demographics
NPI:1255797767
Name:CONCEPCION V. TAN,M.D.
Entity type:Organization
Organization Name:CONCEPCION V. TAN,M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CONCEPCION
Authorized Official - Middle Name:V
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-769-8305
Mailing Address - Street 1:2746 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-4708
Mailing Address - Country:US
Mailing Address - Phone:718-769-8305
Mailing Address - Fax:718-332-2956
Practice Address - Street 1:2746 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-4708
Practice Address - Country:US
Practice Address - Phone:718-769-8305
Practice Address - Fax:718-332-2956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111610261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00638197Medicaid