Provider Demographics
NPI:1740893304
Name:TAN, IRENE BRANDI (OD)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:BRANDI
Last Name:TAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 S SIERRA VISTA AVE # B
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-5104
Mailing Address - Country:US
Mailing Address - Phone:626-757-6407
Mailing Address - Fax:
Practice Address - Street 1:101 N CORONADO DR STE A
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-6359
Practice Address - Country:US
Practice Address - Phone:520-459-1529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34656152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist