Provider Demographics
NPI:1245284959
Name:TANENGGEE, FREDERICK JONES (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:JONES
Last Name:TANENGGEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6355 S BUFFALO DR FL 3
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89113-2133
Mailing Address - Country:US
Mailing Address - Phone:702-216-3346
Mailing Address - Fax:702-671-6883
Practice Address - Street 1:595 W LAKE MEAD PKWY
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7015
Practice Address - Country:US
Practice Address - Phone:702-565-1007
Practice Address - Fax:702-565-0836
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV9921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9921OtherSTATE LICENSE
NV1245284959Medicaid
NVGA681ZMedicare PIN
NV106045Medicare PIN