Provider Demographics
NPI:1043373343
Name:ABOUDIB, TONY G (DC)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:G
Last Name:ABOUDIB
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 CHARTWELL DR.
Mailing Address - Street 2:#2
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686
Mailing Address - Country:US
Mailing Address - Phone:231-421-5213
Mailing Address - Fax:231-421-5215
Practice Address - Street 1:2000 CHARTWELL DR.
Practice Address - Street 2:#2
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686
Practice Address - Country:US
Practice Address - Phone:231-421-5213
Practice Address - Fax:231-421-5215
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC4634111N00000X
MI2301009361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXBLUE CROSSOther603589
TX179719500OtherUS DEPT. OF LABOR
U14175Medicare UPIN
TX603589Medicare ID - Type Unspecified