Provider Demographics
NPI:1457620528
Name:TAN, JENNY (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNY
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 S ANAHEIM BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3848
Mailing Address - Country:US
Mailing Address - Phone:714-826-1200
Mailing Address - Fax:714-665-4652
Practice Address - Street 1:100 S ANAHEIM BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3848
Practice Address - Country:US
Practice Address - Phone:714-826-1200
Practice Address - Fax:714-665-4652
Is Sole Proprietor?:No
Enumeration Date:2011-12-20
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA119050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGF907YMedicare PIN