NPIMap

Individual provider Active NPI

Gordon Tan, M.D.

  • Pediatrics Physician
  • Moreno Valley, CA
National Provider Identifier
1659662583
Registry record updated Nov 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
A122192 Issued in CA
Practice address
12815 Heacock St
Moreno Valley, CA 92553-2836
Phone
(951) 601-6399
NPI assigned
Apr 26, 2011
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 30, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X A122192 CA Primary

Addresses

Primary practice location

12815 Heacock St
Moreno Valley, CA 92553-2836

Mailing address

12815 Heacock St
Moreno Valley, CA 92553-2836

Electronic endpoints 1

TypeEndpointUseAffiliation
SOAP URL https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq Health Information Exchange (HIE) Southern California Permanente Medical Group

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20140723002268 CA Practitioner - Pediatric Medicine 1951527118 Reassigns benefits to 3 organizations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
122192CAMDClinical Social Worker
A122192CAMDPediatrics Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Faculty Physicians and Surgeons of Llusm CurrentSince Jul 1, 2014 Accepting new patients
County of San Bernardino CurrentSince Aug 18, 2015 Accepting new patients
Faculty Physicians and Surgeons of Llusm Current Accepting new patients
Faculty Physicians and Surgeons of Llusm Pediatrics Current Accepting new patients
County of San Bernardino Current Accepting new patients
County of San Bernardino CurrentSince Aug 18, 2015 Accepting new patients
Loma Linda University Children'S Hospital Past Accepting new patients
Faculty Physicians and Surgeons of Llusm Past Accepting new patients
Loma Linda University Medical Center Past Accepting new patients

Locations

303 E Mountain View St
Barstow, CA 92311
Phone (760) 256-4705

7223 Church St
Ste C1
Highland, CA 92346
Phone (909) 425-3946

11370 Anderson St
#B100
Loma Linda, CA 92354
Phone (909) 558-2848

25455 Barton Rd
Ste 108A
Loma Linda, CA 92354
Phone (909) 558-1617

File Number 54701
Los Angeles, CA 90074
Phone (909) 651-4300

26780 Barton Rd
Redlands, CA 92373
Phone (909) 558-5174

351 N Mountain View Ave
Rm 303
Sn Bernrdno, CA 92415

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303776000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1732924800000",
    "number": "1659662583",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "12815 HEACOCK ST",
            "city": "MORENO VALLEY",
            "state": "CA",
            "postal_code": "925532836"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12815 HEACOCK ST",
            "city": "MORENO VALLEY",
            "state": "CA",
            "postal_code": "925532836",
            "telephone_number": "951-601-6399"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "TAN",
        "first_name": "GORDON",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2011-04-26",
        "last_updated": "2024-11-30",
        "certification_date": "2024-11-30",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "CA",
            "license": "A122192",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepicwest.kp.org:14430/Interconnect-prodcalgateway/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/scalceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Southern California Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "10800 Magnolia Ave",
            "city": "Riverside",
            "state": "CA",
            "country_code": "US",
            "postal_code": "925053043",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Moreno Valley, CA

Sources for this page

Verify at the official NPI Registry.