Healthcare Provider Details

I. General information

NPI: 1699415356
Provider Name (Legal Business Name): TABARK ALTAI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 N FRESNO ST
FRESNO CA
93701-2302
US

IV. Provider business mailing address

PO BOX 889442
LOS ANGELES CA
90088-9442
US

V. Phone/Fax

Practice location:
  • Phone: 559-499-6482
  • Fax:
Mailing address:
  • Phone: 559-603-7372
  • Fax: 559-451-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA200089
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA200089
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: