Healthcare Provider Details

I. General information

NPI: 1982934709
Provider Name (Legal Business Name): MICHELLE TABLADA-QUINTANILLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE ESPIRITU TABLADA M.D.

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 S CENTRAL AVE SUITE 310
GLENDALE CA
91204-2530
US

IV. Provider business mailing address

1500 S CENTRAL AVE SUITE 310
GLENDALE CA
91204-2530
US

V. Phone/Fax

Practice location:
  • Phone: 818-500-1369
  • Fax:
Mailing address:
  • Phone: 818-500-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA110098
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number254690
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN8057
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: