Provider Demographics
NPI:1871756254
Name:TAN, NELLY (MD)
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:
Last Name:TAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 WESTWOOD PLAZA
Mailing Address - Street 2:RONALD REGAN UCLA MEDICAL CENTER
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095
Mailing Address - Country:US
Mailing Address - Phone:310-267-8758
Mailing Address - Fax:
Practice Address - Street 1:757 WESTOOD PLZ
Practice Address - Street 2:RRUMC 1621; MAILCODE: 743730
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8358
Practice Address - Country:US
Practice Address - Phone:310-957-9021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2022-10-18
Deactivation Date:2020-02-07
Deactivation Code:
Reactivation Date:2020-04-09
Provider Licenses
StateLicense IDTaxonomies
FLME1486152085R0001X
CAA1147242085R0202X
AZ600182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology