Provider Demographics
NPI:1215940713
Name:TAN, SIOE S (MD)
Entity type:Individual
Prefix:
First Name:SIOE
Middle Name:S
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 S LANCASTER RD
Mailing Address - Street 2:LANCASTER KEIST ADULT OUTPATIENT CLINIC
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75216-4545
Mailing Address - Country:US
Mailing Address - Phone:214-371-6639
Mailing Address - Fax:214-372-6199
Practice Address - Street 1:3330 S LANCASTER RD
Practice Address - Street 2:LANCASTER KEIST ADULT OUTPATIENT CLINIC
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-4545
Practice Address - Country:US
Practice Address - Phone:214-371-6639
Practice Address - Fax:214-372-6199
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE81942084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1042889Medicaid
88125Medicare ID - Type Unspecified
C22469Medicare UPIN