Provider Demographics
NPI:1811997646
Name:TAN, FANG (MD)
Entity type:Individual
Prefix:DR
First Name:FANG
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3232 BRUCE DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94539-5013
Mailing Address - Country:US
Mailing Address - Phone:510-793-2800
Mailing Address - Fax:510-793-2882
Practice Address - Street 1:1895 MOWRY AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1737
Practice Address - Country:US
Practice Address - Phone:510-793-2800
Practice Address - Fax:510-793-2882
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2008-01-07
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CAA81026207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A810260Medicaid
CA00A810260Medicare PIN
CAH77651Medicare UPIN