Provider Demographics
NPI:1841528346
Name:TABILA, EDGAR VINCENT (DO)
Entity type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:VINCENT
Last Name:TABILA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PHR GROUP PROVIDER ENROLLMENT UNIT 3RD FL
Mailing Address - Street 2:393 E WALNUT ST
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91188-0001
Mailing Address - Country:US
Mailing Address - Phone:877-608-0044
Mailing Address - Fax:877-514-0903
Practice Address - Street 1:27450 SCHOENHERR RD
Practice Address - Street 2:SUITE 400
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48088-6683
Practice Address - Country:US
Practice Address - Phone:586-582-7550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-23
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A18381207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty