Provider Demographics
NPI:1104205921
Name:TANGALAKIS, LAUREL LINDA (MD)
Entity type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:LINDA
Last Name:TANGALAKIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LAUREL
Other - Middle Name:LINDA
Other - Last Name:MULDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1717 SHAFFER STREET
Mailing Address - Street 2:SUITE 002
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:269-552-2964
Practice Address - Street 1:1717 SHAFFER ST STE 124
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1629
Practice Address - Country:US
Practice Address - Phone:269-226-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61149321208600000X
MI4301507839208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104205921Medicaid