Provider Demographics
NPI:1215222989
Name:TANG, DOMINIC (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:
Last Name:TANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 W INTERSTATE 20 STE 1
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76017-5851
Mailing Address - Country:US
Mailing Address - Phone:817-784-8268
Mailing Address - Fax:817-417-1150
Practice Address - Street 1:801 W INTERSTATE 20 STE 1
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-417-1150
Is Sole Proprietor?:No
Enumeration Date:2011-06-10
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4909208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX387325901Medicaid
TX387325902Medicaid
TX387325903Medicaid