Basic Information
| Provider Information | |||||||||
| NPI: | 1215940713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | SIOE | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | LANCASTER KEIST ADULT OUTPATIENT CLINIC | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143716639 | ||||||||
| FaxNumber: | 2143726199 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 S LANCASTER RD | ||||||||
| Address2: | LANCASTER KEIST ADULT OUTPATIENT CLINIC | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752164545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143716639 | ||||||||
| FaxNumber: | 2143726199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/30/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | E8194 | TX | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1042889 | 05 | TX | MEDICAID |