Provider Demographics
NPI:1942292602
Name:TAM, JOHN W (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:TAM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 E ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6241
Mailing Address - Country:US
Mailing Address - Phone:626-914-4661
Mailing Address - Fax:626-335-1840
Practice Address - Street 1:222 E ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6241
Practice Address - Country:US
Practice Address - Phone:626-914-4661
Practice Address - Fax:626-335-1840
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2153213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001090Medicaid
CAT11204Medicare UPIN
CAWE2153AMedicare ID - Type UnspecifiedMEDICARE PROVIDER #