Provider Demographics
NPI:1407435670
Name:TAN, DEBORAH (DO)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2740
Mailing Address - Country:US
Mailing Address - Phone:860-889-8331
Mailing Address - Fax:
Practice Address - Street 1:240 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5009
Practice Address - Country:US
Practice Address - Phone:631-726-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-05
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QS1000X
CT79114207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health