Provider Demographics
NPI:1528085388
Name:EKIONG C. TAN M.D., P.A.
Entity type:Organization
Organization Name:EKIONG C. TAN M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EKIENG
Authorized Official - Middle Name:CHUA
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-425-5405
Mailing Address - Street 1:779 MEDICAL DR
Mailing Address - Street 2:SUITE #5
Mailing Address - City:ENGLEWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34223-3980
Mailing Address - Country:US
Mailing Address - Phone:941-425-5405
Mailing Address - Fax:941-475-7689
Practice Address - Street 1:779 MEDICAL DR
Practice Address - Street 2:SUITE #5
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34223-3980
Practice Address - Country:US
Practice Address - Phone:941-425-5405
Practice Address - Fax:941-475-7689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 0045958208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E31879Medicare UPIN
FL73281Medicare ID - Type Unspecified