Healthcare Provider Details

I. General information

NPI: 1821020157
Provider Name (Legal Business Name): TARA ZANDVLIET M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CAMINO DEL RIO SOUTH SUITE 130, ROOM 3
SAN DIEGO CA
92108-3718
US

IV. Provider business mailing address

5694 MISSION CENTER RD # 602-362
SAN DIEGO CA
92108-4355
US

V. Phone/Fax

Practice location:
  • Phone: 619-929-0032
  • Fax: 208-728-8168
Mailing address:
  • Phone: 619-929-0032
  • Fax: 208-728-8168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA71646
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: