Provider Demographics
NPI:1780690230
Name:PANG, JIM JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JIM
Middle Name:
Last Name:PANG
Suffix:JR
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 1:65 GERMANTOWN CT STE 402
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7290
Mailing Address - Country:US
Mailing Address - Phone:901-752-4900
Mailing Address - Fax:901-752-4902
Practice Address - Street 1:65 GERMANTOWN CT STE 402
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7290
Practice Address - Country:US
Practice Address - Phone:901-752-4900
Practice Address - Fax:901-752-4902
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-52262084P0800X
MS140592084P0800X
MO20060310572084P0805X
TN0176592084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0063427OtherBLUE CROSS PROVIDER NUMBE
MS00115350Medicaid
MS02850722Medicaid
MO207980814Medicaid
TN3024414Medicaid
AR127994001Medicaid
MS260000385Medicare PIN
MO000096235Medicare PIN
AR127994001Medicaid
MS02850722Medicaid
MO207980814Medicaid
AR127994001Medicaid
MS02850722Medicaid