Provider Demographics
NPI:1306967609
Name:TAN, BENITA B (MD)
Entity type:Individual
Prefix:
First Name:BENITA
Middle Name:B
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2806 MONTAIR PL
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1680
Mailing Address - Country:US
Mailing Address - Phone:510-487-2909
Mailing Address - Fax:510-477-6767
Practice Address - Street 1:19682 HESPERIAN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4752
Practice Address - Country:US
Practice Address - Phone:510-266-0077
Practice Address - Fax:510-266-0016
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA53599207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A535990Medicaid
CAF93597Medicare UPIN
CA00A535990Medicare ID - Type UnspecifiedPROVIDER NUMBER