Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2080P0202X | Pediatric Cardiologist | G63018 | CA |
NPI | 1275683070 |
---|---|
Provider Name | Jesse A. Tannenbaum |
First Address | Oakland, CA 94612-3429 |
Second Address | Santa Clara, CA 95051-5173 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G630180 | (05) | CA |
B85304 | (02) |