Provider Demographics
NPI:1588108161
Name:TABAK, MOISHE
Entity type:Individual
Prefix:MR
First Name:MOISHE
Middle Name:
Last Name:TABAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:TABAK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2011 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-4507
Mailing Address - Country:US
Mailing Address - Phone:718-215-1177
Mailing Address - Fax:718-215-1171
Practice Address - Street 1:2011 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4507
Practice Address - Country:US
Practice Address - Phone:718-215-1177
Practice Address - Fax:718-215-1171
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1922463827Medicaid