Provider Demographics
NPI:1467413435
Name:TANGUAY, MARY ALICE ADELINE (OD)
Entity Type:Individual
Prefix:DR
First Name:MARY ALICE
Middle Name:ADELINE
Last Name:TANGUAY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 116239
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75011-6239
Mailing Address - Country:US
Mailing Address - Phone:972-492-6588
Mailing Address - Fax:972-492-5337
Practice Address - Street 1:1850 ROSEMEADE
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75007
Practice Address - Country:US
Practice Address - Phone:972-492-6588
Practice Address - Fax:972-492-5337
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-30
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2904T6152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00E11KMedicare PIN
T16204Medicare UPIN