Provider Demographics
NPI:1578644555
Name:LANGE, TISHANA R (MD)
Entity Type:Individual
Prefix:MRS
First Name:TISHANA
Middle Name:R
Last Name:LANGE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:4845 KNIGHTSBRIDGE BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-2463
Mailing Address - Country:US
Mailing Address - Phone:614-299-5838
Mailing Address - Fax:614-299-5929
Practice Address - Street 1:4845 KNIGHTSBRIDGE BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-2463
Practice Address - Country:US
Practice Address - Phone:614-299-5838
Practice Address - Fax:614-299-5929
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-10-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35079071L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH235003Medicaid
OH2350003Medicaid
OH235003Medicaid
OHH69979Medicare UPIN