Provider Demographics
NPI:1982764361
Name:KEN C. TAN, M.D.
Entity Type:Organization
Organization Name:KEN C. TAN, M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RYONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-964-6352
Mailing Address - Street 1:PO BOX 4007
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-0007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:250 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-4218
Practice Address - Country:US
Practice Address - Phone:626-857-3140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2007-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12782207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A319380Medicaid
CA12782Medicare UPIN
CAW19515Medicare ID - Type Unspecified