Provider Demographics
NPI:1316948391
Name:TAN, CORNELIA W (MD)
Entity type:Individual
Prefix:
First Name:CORNELIA
Middle Name:W
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:PO BOX 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:303 E OVERTON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-5946
Practice Address - Country:US
Practice Address - Phone:214-266-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2363207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX139120306Medicaid
TX139120312Medicaid
TX139120313Medicaid
TX139120308Medicaid
TX139120302Medicaid
TX139120303Medicaid
TX139120314Medicaid
TX139120304Medicaid
TX139120305Medicaid
TX139120309Medicaid
TX139120307Medicaid
TX139120310Medicaid
TX86X875Medicare PIN
TX139120307Medicaid