Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RR0500X | Rheumatology | 165674 | NY |
NPI | 1083770580 |
---|---|
Provider Name | Mr. Mark Tan |
First Address | Smithtown, NY 11787 |
Second Address | Smithtown, NY 11787 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2006 |
Last Update Date | 27/07/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00986705 | (05) | NY |
C58894 | (02) | NY |