Provider Demographics
NPI:1104809946
Name:TAN, RAYMOND CHARLES (MD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:CHARLES
Last Name: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:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94526-0756
Mailing Address - Country:US
Mailing Address - Phone:877-866-0914
Mailing Address - Fax:916-303-8568
Practice Address - Street 1:7887 N CEDAR AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2685
Practice Address - Country:US
Practice Address - Phone:559-437-1000
Practice Address - Fax:559-437-3870
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-25
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA732522085R0001X
WAMD0605805702085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA732520OtherBLUE SHIELD
CAOOA732520OtherMEDICARE ID
CA107622Medicare UPIN
CAOOA732520Medicare ID - Type Unspecified