Provider Demographics
NPI:1548239635
Name:TAM, TACKSON (MD)
Entity type:Individual
Prefix:
First Name:TACKSON
Middle Name:
Last Name:TAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 W LA VETA AVE STE 750
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4312
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1010 W LA VETA AVE STE 750
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4312
Practice Address - Country:US
Practice Address - Phone:714-361-6600
Practice Address - Fax:714-919-8804
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1912919804OtherMEDI-CAL
CA110200071OtherRAIL ROAD MEDICARE - PROVIDER PTAN
CA1912919804OtherNPI - TYPE 2
CACG5665OtherRAIL ROAD MEDICARE - GROUP PTAN
CAW1514OtherMEDICARE PTAN - TYPE 2
CAF12029Medicare UPIN
CACG5665OtherRAIL ROAD MEDICARE - GROUP PTAN
CAWG70073DMedicare PIN
CAW11996OtherMEDICARE PTAN - TYPE 2