Provider Demographics
NPI:1306077144
Name:JOHN J K TAN MD PA
Entity type:Organization
Organization Name:JOHN J K TAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:J K
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-746-4855
Mailing Address - Street 1:PO BOX 3405
Mailing Address - Street 2:MEMORIAL STATION
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-3405
Mailing Address - Country:US
Mailing Address - Phone:973-746-4855
Mailing Address - Fax:973-746-5305
Practice Address - Street 1:77 PARK ST
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2962
Practice Address - Country:US
Practice Address - Phone:973-746-4855
Practice Address - Fax:973-746-5305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-28
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO2451600261QM2500X
207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ053701Medicare UPIN
NJ1659450377Medicare PIN