Provider Demographics
NPI:1164853560
Name:TANGUILAN, MARY GRACE (MD)
Entity Type:Individual
Prefix:
First Name:MARY GRACE
Middle Name:
Last Name:TANGUILAN
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3401 BOX HILL CORPORATE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ABINGDON
Mailing Address - State:MD
Mailing Address - Zip Code:21009-1251
Mailing Address - Country:US
Mailing Address - Phone:410-671-0017
Mailing Address - Fax:410-671-7072
Practice Address - Street 1:3401 BOX HILL CORPORATE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:ABINGDON
Practice Address - State:MD
Practice Address - Zip Code:21009-1251
Practice Address - Country:US
Practice Address - Phone:410-671-0017
Practice Address - Fax:410-671-7072
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-10
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDD00077329207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1164853560OtherNPI