Provider Demographics
NPI:1639132327
Name:TADLOCK, HUGH M (MD)
Entity Type:Individual
Prefix:
First Name:HUGH
Middle Name:M
Last Name:TADLOCK
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:PO BOX 4063
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-4063
Mailing Address - Country:US
Mailing Address - Phone:512-508-1809
Mailing Address - Fax:
Practice Address - Street 1:1605 ROCK PRAIRIE RD
Practice Address - Street 2:SUITE 102
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-8358
Practice Address - Country:US
Practice Address - Phone:512-508-1809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX742587049OtherTAX ID
TXB26830Medicare UPIN
TX00QV80Medicare ID - Type Unspecified
TX131528505Medicaid