Provider Demographics
NPI:1447578992
Name:TONG, THEN ETHAN VAN (DO)
Entity type:Individual
Prefix:DR
First Name:THEN
Middle Name:ETHAN VAN
Last Name:TONG
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:THEN
Other - Middle Name:VAN
Other - Last Name:TONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1201 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50316-2339
Mailing Address - Country:US
Mailing Address - Phone:515-266-1000
Mailing Address - Fax:515-266-1824
Practice Address - Street 1:1201 PENN AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2339
Practice Address - Country:US
Practice Address - Phone:515-266-1000
Practice Address - Fax:515-266-1824
Is Sole Proprietor?:No
Enumeration Date:2010-05-08
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA4475207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1447578992Medicaid
IAP01242999OtherRR MEDICARE
IA719260129Medicare PIN