Provider Demographics
NPI:1235287954
Name:TANGVALD, THOR IV (MD)
Entity type:Individual
Prefix:
First Name:THOR
Middle Name:
Last Name:TANGVALD
Suffix:IV
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636256
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-585-6200
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:3200 BURNET AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3019
Practice Address - Country:US
Practice Address - Phone:513-558-7700
Practice Address - Fax:513-558-5055
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY331412084P0800X
OH35.0590782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64938137Medicaid
KY0549601Medicare ID - Type Unspecified
KYE76111Medicare UPIN