Provider Demographics
NPI:1366734717
Name:TAN, GARY (DO)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:TAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:380 SUMMIT AVE., MSO PHYSICIAN BILLING
Mailing Address - Street 2:
Mailing Address - City:STEUBENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43952-2667
Mailing Address - Country:US
Mailing Address - Phone:740-283-7597
Mailing Address - Fax:740-283-7460
Practice Address - Street 1:1 ROSS PARK BLVD STE G-3
Practice Address - Street 2:
Practice Address - City:STEUBENVILLE
Practice Address - State:OH
Practice Address - Zip Code:43952-2681
Practice Address - Country:US
Practice Address - Phone:740-266-5969
Practice Address - Fax:740-266-5970
Is Sole Proprietor?:No
Enumeration Date:2011-05-04
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA303775208800000X
NJ25MB09553900208800000X
OH12699208800000X
WV3182208800000X
OH34.012699208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0244510Medicaid