Provider Demographics
NPI:1134351950
Name:GO, JON AVERY TAN
Entity type:Individual
Prefix:
First Name:JON AVERY
Middle Name:TAN
Last Name:GO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JON AVERY
Other - Middle Name:T
Other - Last Name:GO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78291-0087
Mailing Address - Country:US
Mailing Address - Phone:210-358-9172
Mailing Address - Fax:210-358-9183
Practice Address - Street 1:701 S ZARZAMORA ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-5209
Practice Address - Country:US
Practice Address - Phone:210-358-7000
Practice Address - Fax:210-358-7406
Is Sole Proprietor?:No
Enumeration Date:2009-08-12
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD 18347207R00000X
TXP1643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine