Provider Demographics
NPI:1841451481
Name:JESSELA D. TAN, M.D., P.L.L.C.
Entity type:Organization
Organization Name:JESSELA D. TAN, M.D., P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JESSELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:214-703-1900
Mailing Address - Street 1:3523 MCKINNEY AVE
Mailing Address - Street 2:#735
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1401
Mailing Address - Country:US
Mailing Address - Phone:214-703-1900
Mailing Address - Fax:214-703-1901
Practice Address - Street 1:7501 LAKEVIEW PKWY
Practice Address - Street 2:SUITE 140
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-9322
Practice Address - Country:US
Practice Address - Phone:972-526-7500
Practice Address - Fax:972-526-7501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-17
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4580207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty