Provider Demographics
NPI:1841373438
Name:TAN, VIRAK (MD)
Entity type:Individual
Prefix:
First Name:VIRAK
Middle Name:
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 1:30 BERGEN ST
Mailing Address - Street 2:ADMC 12 1205
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-3000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 BERGEN ST
Practice Address - Street 2:DOC 1200
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2425
Practice Address - Country:US
Practice Address - Phone:973-972-2150
Practice Address - Fax:973-972-2155
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07231500207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8555907Medicaid
NJ049371Medicare PIN
NJ8555907Medicaid