Provider Demographics
NPI:1962403097
Name:TAN, CONCEPCION V (MD)
Entity type:Individual
Prefix:
First Name:CONCEPCION
Middle Name:V
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MIDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225
Mailing Address - Country:US
Mailing Address - Phone:718-469-1717
Mailing Address - Fax:718-332-2956
Practice Address - Street 1:2746 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229
Practice Address - Country:US
Practice Address - Phone:718-769-8305
Practice Address - Fax:718-332-2956
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY111610208000000X, 2080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00638197Medicaid
NY85A06Medicare ID - Type Unspecified
NY00638197Medicaid