Provider Demographics
NPI:1215168653
Name:TACKIE, IRMGARD UNA (MD)
Entity type:Individual
Prefix:
First Name:IRMGARD
Middle Name:UNA
Last Name:TACKIE
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 1:16096 PITZER ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4530
Mailing Address - Country:US
Mailing Address - Phone:865-591-1988
Mailing Address - Fax:
Practice Address - Street 1:15290 SUMMIT AVE
Practice Address - Street 2:SUITE B
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-0240
Practice Address - Country:US
Practice Address - Phone:909-225-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118539208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics