Basic Information
| Provider Information | |||||||||
| NPI: | 1518981307 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAM | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | S. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TAM | ||||||||
| OtherFirstName: | SIN-MAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1870 LUNDY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951311826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085739686 | ||||||||
| FaxNumber: | 4089220872 | ||||||||
| Practice Location | |||||||||
| Address1: | 1870 LUNDY AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951311826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085739686 | ||||||||
| FaxNumber: | 4089220872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 03/03/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A62269 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8516931 | 05 | CA | MEDICAID |