Basic Information
| Provider Information | |||||||||
| NPI: | 1114957628 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAM | ||||||||
| FirstName: | TONY | ||||||||
| MiddleName: | YUK MAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 STANDIFORD AVE STE F | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953501159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 COFFEE RD | ||||||||
| Address2: | |||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 953552803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2095795628 | ||||||||
| FaxNumber: | 2095795637 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | G71710 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | G71710 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 2086S0129X | G71710 | CA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 208C00000X | G71710 | CA | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | G71710 | CA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00G717100 | 05 | CA | MEDICAID | 00G717102 | 01 | PROVIDER TRANSACTION ACCESS NUMBER (PTAN) | OTHER |