Provider Demographics
NPI:1912982612
Name:SO, ALEJANDRO TAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ALEJANDRO
Middle Name:TAN
Last Name:SO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 74TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1847
Mailing Address - Country:US
Mailing Address - Phone:718-651-2800
Mailing Address - Fax:718-779-5116
Practice Address - Street 1:4108 74TH ST
Practice Address - Street 2:
Practice Address - City:ELMHURST
Practice Address - State:NY
Practice Address - Zip Code:11373-1847
Practice Address - Country:US
Practice Address - Phone:718-651-2800
Practice Address - Fax:718-779-5116
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121831174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE36938Medicare UPIN
NY441022517Medicare PIN