Basic Information
Provider Information | |||||||||
NPI: | 1346458825 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TANG | ||||||||
FirstName: | JOHN CHRISTOPHER | ||||||||
MiddleName: | FORMOSO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 250 N SHADELAND AVE | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462194959 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13100 E 136TH ST STE 3600 | ||||||||
Address2: |   | ||||||||
City: | FISHERS | ||||||||
State: | IN | ||||||||
PostalCode: | 460379822 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179440980 | ||||||||
FaxNumber: | 3179441497 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 11/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 5101015998 | MI | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RG0100X | 02003779A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 201012180 | 05 | IN |   | MEDICAID | M400039154 | 01 | IN | MEDICARE PTAN | OTHER |