Provider Demographics
NPI:1114506110
Name:TAN, JEDIDIAH LAGOS (RPT, DPT)
Entity Type:Individual
Prefix:
First Name:JEDIDIAH
Middle Name:LAGOS
Last Name:TAN
Suffix:
Gender:M
Credentials:RPT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12602 CARLISLE FALLS CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-1594
Mailing Address - Country:US
Mailing Address - Phone:832-379-0668
Mailing Address - Fax:
Practice Address - Street 1:4102 VETERANS DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-2950
Practice Address - Country:US
Practice Address - Phone:832-379-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2022-07-29
Deactivation Date:2022-03-19
Deactivation Code:
Reactivation Date:2022-05-09
Provider Licenses
StateLicense IDTaxonomies
TX1342184225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist