Healthcare Provider Details

I. General information

NPI: 1457732612
Provider Name (Legal Business Name): TABATA BAHIENSE GRODIN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TABATA BAHIENSE M.D.

II. Dates (important events)

Enumeration Date: 06/13/2015
Last Update Date: 04/07/2022
Certification Date: 03/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 S SEACREST BLVD STE 220
BOYNTON BEACH FL
33435-7965
US

IV. Provider business mailing address

2800 S SEACREST BLVD STE 220
BOYNTON BEACH FL
33435-7965
US

V. Phone/Fax

Practice location:
  • Phone: 561-413-2850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME138810
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: