Healthcare Provider Details

I. General information

NPI: 1689170516
Provider Name (Legal Business Name): NITIN PRAVEEN TALLAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2018
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MUIR RD PHYSICAL MEDICINE & REHABILITATION
MARTINEZ CA
94553
US

IV. Provider business mailing address

200 MUIR RD PHYSICAL MEDICINE & REHABILITATION
MARTINEZ CA
94553-4614
US

V. Phone/Fax

Practice location:
  • Phone: 925-372-1000
  • Fax:
Mailing address:
  • Phone: 925-372-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA175972
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: