Healthcare Provider Details

I. General information

NPI: 1952564866
Provider Name (Legal Business Name): VIVIAN TANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 10TH AVE MAIMONIDES MEDICAL CENTER, DEPARTMENT OF PEDIATRIC GI
BROOKLYN NY
11219-2916
US

IV. Provider business mailing address

977 48TH ST
BROOKLYN NY
11219-2919
US

V. Phone/Fax

Practice location:
  • Phone: 718-283-7329
  • Fax: 718-635-6149
Mailing address:
  • Phone: 718-283-7329
  • Fax: 718-635-6149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD442856
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number274153
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: