Provider Demographics
NPI:1174562540
Name:TANEN, SHLOMO MARK (MD)
Entity type:Individual
Prefix:
First Name:SHLOMO
Middle Name:MARK
Last Name:TANEN
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 1:11702 GAINSBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3246
Mailing Address - Country:US
Mailing Address - Phone:703-201-0830
Mailing Address - Fax:
Practice Address - Street 1:11702 GAINSBOROUGH RD
Practice Address - Street 2:
Practice Address - City:POTOMAC
Practice Address - State:MD
Practice Address - Zip Code:20854-3246
Practice Address - Country:US
Practice Address - Phone:703-201-0830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-04
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0130000215174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0130000215OtherBOARD OF MEDICINE LICENSE
VA00-60-2846-2Medicaid
VA085814OtherANTHEM
VAA302-0001OtherBCBSNCA
VAA302-0001OtherBCBSNCA
VA085814OtherANTHEM
VAE23100Medicare UPIN
VA00-60-2846-2Medicaid