Provider Demographics
NPI:1871524082
Name:TANTE-TAKOUGANG, PRUDENCE (MD)
Entity type:Individual
Prefix:
First Name:PRUDENCE
Middle Name:
Last Name:TANTE-TAKOUGANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6350 GLENWAY AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45211-6378
Mailing Address - Country:US
Mailing Address - Phone:513-481-3400
Mailing Address - Fax:513-481-9901
Practice Address - Street 1:6350 GLENWAY AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-6378
Practice Address - Country:US
Practice Address - Phone:513-481-3400
Practice Address - Fax:513-481-9901
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35082744207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2466675Medicaid
OH2466675Medicaid
OH4114096Medicare PIN
OHTA4114094Medicare PIN
OHH93096Medicare UPIN
OH4114095Medicare PIN