Healthcare Provider Details

I. General information

NPI: 1902115793
Provider Name (Legal Business Name): MARK TAMBELLINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 09/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 BROWER CT
GRANITE BAY CA
95746-6742
US

IV. Provider business mailing address

5021 BROWER CT
GRANITE BAY CA
95746-6742
US

V. Phone/Fax

Practice location:
  • Phone: 916-761-9399
  • Fax: 916-774-4360
Mailing address:
  • Phone: 916-761-9399
  • Fax: 916-774-4360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG37599
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: