Provider Demographics
NPI:1841990637
Name:TANG, SOPHEAK
Entity type:Individual
Prefix:
First Name:SOPHEAK
Middle Name:
Last Name:TANG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:174 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4146
Mailing Address - Country:US
Mailing Address - Phone:203-793-7948
Mailing Address - Fax:203-678-4156
Practice Address - Street 1:174 CENTER ST
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4146
Practice Address - Country:US
Practice Address - Phone:203-793-7948
Practice Address - Fax:203-678-4156
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1584156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician