Provider Demographics
NPI:1982157996
Name:TIANGSON, MARIBONN
Entity Type:Individual
Prefix:
First Name:MARIBONN
Middle Name:
Last Name:TIANGSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-4004
Mailing Address - Fax:
Practice Address - Street 1:3012 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6144
Practice Address - Country:US
Practice Address - Phone:219-877-3841
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.068456207R00000X
IN01082487A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine