Provider Demographics
NPI:1457641714
Name:TANGCHAIVANG, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:TANGCHAIVANG
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 1:10250 SANTA MONICA BLVD STE 1450
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-6495
Mailing Address - Country:US
Mailing Address - Phone:415-349-0850
Mailing Address - Fax:415-354-3430
Practice Address - Street 1:10250 SANTA MONICA BLVD STE 1450
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-6495
Practice Address - Country:US
Practice Address - Phone:415-349-0850
Practice Address - Fax:415-354-3430
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine