Healthcare Provider Details

I. General information

NPI: 1760722433
Provider Name (Legal Business Name): KEVEN TAGDIRI M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 MANCHESTER AVE SUITE 103
ENCINITAS CA
92024-4938
US

IV. Provider business mailing address

4401 MANCHESTER AVE SUITE 103
ENCINITAS CA
92024-4938
US

V. Phone/Fax

Practice location:
  • Phone: 858-756-3021
  • Fax:
Mailing address:
  • Phone: 858-756-3021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number871851
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVEN TAGDIRI
Title or Position: OWNER
Credential: M.D.
Phone: 858-756-3021