Provider Demographics
NPI:1215960844
Name:TANASOVICH, CHERYL ANN (MD)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANN
Last Name:TANASOVICH
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 1:1300 S ELISEO DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2023
Mailing Address - Country:US
Mailing Address - Phone:415-925-0550
Mailing Address - Fax:415-925-9062
Practice Address - Street 1:1300 S ELISEO DR
Practice Address - Street 2:SUITE 207
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2023
Practice Address - Country:US
Practice Address - Phone:415-925-0550
Practice Address - Fax:415-925-9062
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53455207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G534551OtherMEDI-CAL PROVIDER NUMBER
CA931041613OtherTRICARE PROVIDER NUMBER
CA0004133440OtherAETNA PROVIDER NUMBER
CA00G534550OtherBLUE SHIELD PROV #
CA070003525OtherRAILROAD MEDICARE PROV #
CA070003525OtherRAILROAD MEDICARE PROV #
CA00G534550Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER