Provider Demographics
NPI:1932156205
Name:LOPEZ-TAN, DANIEL WONG (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:WONG
Last Name:LOPEZ-TAN
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 1:15575 GRANDVIEW DRIVE LOWER
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2982
Mailing Address - Country:US
Mailing Address - Phone:414-755-9104
Mailing Address - Fax:414-777-1812
Practice Address - Street 1:850 ELM GROVE RD
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2527
Practice Address - Country:US
Practice Address - Phone:262-879-8014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI35095207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32414400Medicaid
WI32414400Medicaid
WI000268925Medicare ID - Type Unspecified