Provider Demographics
NPI:1710970058
Name:KANJO, TADGE M (MD)
Entity Type:Individual
Prefix:
First Name:TADGE
Middle Name:M
Last Name:KANJO
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 1:196 ARROWHEAD DR
Mailing Address - Street 2:SUITE 6
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82930-8752
Mailing Address - Country:US
Mailing Address - Phone:307-783-8398
Mailing Address - Fax:307-783-8399
Practice Address - Street 1:196 ARROWHEAD DR
Practice Address - Street 2:SUITE 6
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-8752
Practice Address - Country:US
Practice Address - Phone:307-783-8398
Practice Address - Fax:307-783-8399
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41467-020174400000X, 208600000X
WYTL1909208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33338100Medicaid
WI22235Medicare ID - Type Unspecified
H22053Medicare UPIN