Provider Demographics
NPI:1104581248
Name:TAM, IVAN (DPT)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1831 SHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-6619
Mailing Address - Country:US
Mailing Address - Phone:718-552-7267
Mailing Address - Fax:
Practice Address - Street 1:4 MEETING HOUSE RD STE 5
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-2775
Practice Address - Country:US
Practice Address - Phone:978-970-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-03
Last Update Date:2022-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047376225100000X
CT13183225100000X
MA26504225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist