Provider Demographics
NPI:1649474032
Name:DANG, TOM TIEN (DPM)
Entity type:Individual
Prefix:
First Name:TOM
Middle Name:TIEN
Last Name:DANG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-1146
Mailing Address - Country:US
Mailing Address - Phone:706-335-4884
Mailing Address - Fax:706-336-8798
Practice Address - Street 1:679 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-1146
Practice Address - Country:US
Practice Address - Phone:706-335-4884
Practice Address - Fax:706-336-8798
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000824213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000771427FMedicaid
GA000771427GMedicaid
GA300029612CMedicaid
GAU68457Medicare UPIN
GA000771427FMedicaid
GAGRP3408Medicare ID - Type UnspecifiedGROUP