Healthcare Provider Details

I. General information

NPI: 1053399162
Provider Name (Legal Business Name): TATIANA M. ZEBALLOS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 07/16/2023
Certification Date: 07/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 VIA ARCO
PALOS VERDES ESTATES CA
90274-2055
US

IV. Provider business mailing address

1408 VIA ARCO
PALOS VERDES ESTATES CA
90274-2055
US

V. Phone/Fax

Practice location:
  • Phone: 202-285-4550
  • Fax:
Mailing address:
  • Phone: 202-285-4550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD425510
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME127937
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberC164447
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2080B0002X
TaxonomyPediatric Obesity Medicine Physician
License NumberC164447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: