Provider Demographics
NPI:1528164308
Name:TAN, EULOGIO E (MD)
Entity type:Individual
Prefix:DR
First Name:EULOGIO
Middle Name:E
Last Name:TAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5737 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-8124
Mailing Address - Country:US
Mailing Address - Phone:337-304-0523
Mailing Address - Fax:
Practice Address - Street 1:639 LOTUS DR N
Practice Address - Street 2:SUITE B
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-2926
Practice Address - Country:US
Practice Address - Phone:985-626-6133
Practice Address - Fax:985-626-6136
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA03820R207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1158224Medicaid
LA4A605Medicare ID - Type Unspecified
LAC22460Medicare UPIN