Provider Demographics
NPI:1699188912
Name:TJAHJADI, MICHAEL LEON (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEON
Last Name:TJAHJADI
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 1:14 MEDICAL PARK STE 400
Mailing Address - Street 2:PEDIATRIC OUTPATIENT CLINIC
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203
Mailing Address - Country:US
Mailing Address - Phone:803-434-6155
Mailing Address - Fax:803-434-6979
Practice Address - Street 1:14 MEDICAL PARK STE 400
Practice Address - Street 2:PEDIATRIC OUTPATIENT CLINIC
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-434-6155
Practice Address - Fax:803-434-6979
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL36929208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics