Provider Demographics
NPI:1063792646
Name:TANG, LISA M
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:TANG
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 1:1735 N PAULINA ST
Mailing Address - Street 2:#512
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1133
Mailing Address - Country:US
Mailing Address - Phone:708-749-9061
Mailing Address - Fax:
Practice Address - Street 1:6800 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3643
Practice Address - Country:US
Practice Address - Phone:708-749-9061
Practice Address - Fax:708-749-2478
Is Sole Proprietor?:No
Enumeration Date:2011-08-26
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051291370183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist