Provider Demographics
NPI:1417040114
Name:TANG, TONY THIEN (M D)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:THIEN
Last Name:TANG
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 SOUTH GRAND BLVD.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63111
Mailing Address - Country:US
Mailing Address - Phone:314-752-8600
Mailing Address - Fax:314-752-8601
Practice Address - Street 1:4675 SOUTH GRAND BLVD.
Practice Address - Street 2:
Practice Address - City:ST. LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63111
Practice Address - Country:US
Practice Address - Phone:314-752-8600
Practice Address - Fax:314-752-8601
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003024222207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I11532Medicare UPIN