Healthcare Provider Details

I. General information

NPI: 1285952655
Provider Name (Legal Business Name): OLIVER O TANNOUS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 DICKINSON ST SUITE 121, MC 8894
SAN DIEGO CA
92103-1913
US

IV. Provider business mailing address

350 DICKINSON STREET SUITE 121
SAN DIEGO CA
92103
US

V. Phone/Fax

Practice location:
  • Phone: 858-248-6456
  • Fax:
Mailing address:
  • Phone: 858-248-6456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberA134817
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA134817
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: