Provider Demographics
NPI:1396747721
Name:TAN, STANLEY ANDREW (MD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:ANDREW
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 1:20642 JOHN DR
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94546-5103
Mailing Address - Country:US
Mailing Address - Phone:510-785-5000
Mailing Address - Fax:
Practice Address - Street 1:20642 JOHN DR
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5103
Practice Address - Country:US
Practice Address - Phone:510-785-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23082207R00000X, 207RE0101X
FLME94328207RE0101X
NC2003-00713207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89133MTMedicaid
NC2017381Medicare ID - Type UnspecifiedPROVIDER NUMBER
NC89133MTMedicaid