Provider Demographics
NPI:1760466585
Name:TANGALOS, THEODORE L (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:L
Last Name:TANGALOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43445 SCHOENHERR RD
Mailing Address - Street 2:STE 2
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1961
Mailing Address - Country:US
Mailing Address - Phone:586-726-4823
Mailing Address - Fax:586-726-8365
Practice Address - Street 1:43445 SCHOENHERR RD
Practice Address - Street 2:STE 2
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1961
Practice Address - Country:US
Practice Address - Phone:586-726-4823
Practice Address - Fax:586-726-8365
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3475867Medicaid
0F37078Medicare ID - Type Unspecified
MI3475867Medicaid