Provider Demographics
NPI:1073528956
Name:TANG, TEODORO C JR (DC)
Entity Type:Individual
Prefix:
First Name:TEODORO
Middle Name:C
Last Name:TANG
Suffix:JR
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 1:413 E MCCARTY ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-3141
Mailing Address - Country:US
Mailing Address - Phone:314-322-4653
Mailing Address - Fax:
Practice Address - Street 1:3349 AMERICAN AVE STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1079
Practice Address - Country:US
Practice Address - Phone:573-635-9655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006001147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOV08672OtherMERCY
MO4400155OtherUNITED HEALTH CARE
MO000014746Medicare ID - Type Unspecified