Provider Demographics
NPI:1235287954
Name:TANGVALD, THOR IV (MD)
Entity Type:Individual
Prefix:
First Name:THOR
Middle Name:
Last Name:TANGVALD
Suffix:IV
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 1:103 LANDMARK DR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:BELLEVUE
Mailing Address - State:KY
Mailing Address - Zip Code:41073-1393
Mailing Address - Country:US
Mailing Address - Phone:859-292-3900
Mailing Address - Fax:859-292-3903
Practice Address - Street 1:103 LANDMARK DR
Practice Address - Street 2:SUITE 240
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073-1393
Practice Address - Country:US
Practice Address - Phone:859-292-3900
Practice Address - Fax:859-292-3903
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY331412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64938137Medicaid
KY0549601Medicare ID - Type Unspecified
KYE76111Medicare UPIN