Provider Demographics
NPI:1992870299
Name:TARIQ, SHABANA N (MD)
Entity type:Individual
Prefix:
First Name:SHABANA
Middle Name:N
Last Name:TARIQ
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 1:11021 VANALDEN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91326-2324
Mailing Address - Country:US
Mailing Address - Phone:818-831-5379
Mailing Address - Fax:
Practice Address - Street 1:14445 OLIVE VIEW DR
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1437
Practice Address - Country:US
Practice Address - Phone:818-364-3205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFB061ZMedicare PIN