Provider Demographics
NPI:1205862778
Name:TAN, LUNG KANG (DPM)
Entity Type:Individual
Prefix:DR
First Name:LUNG
Middle Name:KANG
Last Name:TAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 FARAON ST STE 120
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-3800
Mailing Address - Country:US
Mailing Address - Phone:816-271-1067
Mailing Address - Fax:816-271-1071
Practice Address - Street 1:5202 FARAON ST STE A
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-3840
Practice Address - Country:US
Practice Address - Phone:816-271-1067
Practice Address - Fax:816-271-1071
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004035104213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO301208005Medicaid
P00353075OtherRAILROAD
K82E829AMedicare PIN
4238380001Medicare NSC
MO701E829Medicare PIN
MO301208005Medicaid
4238380002Medicare NSC
4238380003Medicare NSC
P00353075OtherRAILROAD
4238380005Medicare NSC
K82E829Medicare PIN