MEDICARE: DR. RODOLFO T. TABILA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A38544	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05D0865425	OTHER	CA	CLIA ID NO
2	05D0973914	OTHER	CA	CLIA ID NO
3	A38544	OTHER	CA	STATE LICENSE NO
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962538181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RODOLFO T. TABILA M.D.

Provider Business Mailing Address
First Line	:	1339 W WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-3116
Country	:	US
Telephone Number	:	562-492-6698
Fax Number	:	562-492-9553

Provider Business Practice Location Address
First Line	:	1339 W WILLOW ST
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90810-3116
Country	:	US
Telephone Number	:	562-492-6698
Fax Number	:	562-492-9553

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	03/30/2020

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