Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0214X | Pediatric Pulmonologist | A76613 | CA |
NPI | 1295889905 |
---|---|
Provider Name | Dr. Mary Anne Arcilla Tablizo |
First Address | Madera, CA 93638-8761 |
Second Address | Madera, CA 93638-8761 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A76613 | STATE LICENSE NUMBER (01) | CA |
GR0103350 | GROUP PROVIDER NUMBER (01) | CA |