Provider Demographics
NPI:1649303934
Name:TAN, JACKSON CHIO (MD, PHD, PT)
Entity type:Individual
Prefix:
First Name:JACKSON
Middle Name:CHIO
Last Name:TAN
Suffix:
Gender:M
Credentials:MD, PHD, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6144 GAZEBO PARK PL S STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-1086
Mailing Address - Country:US
Mailing Address - Phone:904-260-3011
Mailing Address - Fax:904-260-3170
Practice Address - Street 1:6144 GAZEBO PARK PL S STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-1086
Practice Address - Country:US
Practice Address - Phone:904-260-3011
Practice Address - Fax:904-260-3170
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2023-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0071587225400000X
FLME71587208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH69836Medicare UPIN