Provider Demographics
NPI:1386653996
Name:MOSHE TABAK M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MOSHE TABAK M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOSHE
Authorized Official - Middle Name:
Authorized Official - Last Name:TABAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-932-2780
Mailing Address - Street 1:PO BOX 3098
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3098
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:201 W GARVEY AVE
Practice Address - Street 2:#201
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-7418
Practice Address - Country:US
Practice Address - Phone:626-280-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A402570Medicaid
CA00A402570OtherBLUE SHIELD
CAW18295Medicare ID - Type Unspecified