Provider Demographics
NPI:1548344625
Name:BENITA B TAN MD INC
Entity type:Organization
Organization Name:BENITA B TAN MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENITA
Authorized Official - Middle Name:B
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:510-266-0077
Mailing Address - Street 1:2806 MONTAIR PLACE
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587
Mailing Address - Country:US
Mailing Address - Phone:510-266-0077
Mailing Address - Fax:510-266-0016
Practice Address - Street 1:19682 HESPERIAN BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-4752
Practice Address - Country:US
Practice Address - Phone:510-266-0077
Practice Address - Fax:510-266-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53599207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A535990Medicaid
CA00A535990Medicaid
CA00A535990Medicare ID - Type Unspecified