Provider Demographics
NPI:1699765305
Name:JOHN W. TAM PODIATRY CORP
Entity type:Organization
Organization Name:JOHN W. TAM PODIATRY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:TAM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:626-914-4661
Mailing Address - Street 1:222 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6241
Mailing Address - Country:US
Mailing Address - Phone:626-914-4661
Mailing Address - Fax:626-335-1840
Practice Address - Street 1:222 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6241
Practice Address - Country:US
Practice Address - Phone:626-914-4661
Practice Address - Fax:626-335-1840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2153213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E21530Medicaid
CA4139600001OtherMEDICARE DME
CA4139600001OtherMEDICARE DME
CA4139600001Medicare NSC