Provider Demographics
NPI:1285780692
Name:ADVANCED GASTROENTEROLOGY OF MONTEREY COUNTY MEDICAL CORP
Entity type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY OF MONTEREY COUNTY MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUMTAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:TABBAA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:831-755-6352
Mailing Address - Street 1:395 DEL MONTE CENTER STE 173
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-6156
Mailing Address - Country:US
Mailing Address - Phone:831-755-6352
Mailing Address - Fax:831-372-1666
Practice Address - Street 1:1441 CONSTITUTION BLVD
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3100
Practice Address - Country:US
Practice Address - Phone:831-755-6352
Practice Address - Fax:831-755-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA54688207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A546880Medicaid
CA00A546880Medicaid
CA00A56880Medicare ID - Type Unspecified