Healthcare Provider Details

I. General information

NPI: 1093901795
Provider Name (Legal Business Name): BRUCE TABAK, D.P.M.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 S WASHINGTON ST
OXFORD MI
48371-4981
US

IV. Provider business mailing address

129 S WASHINGTON ST
OXFORD MI
48371-4981
US

V. Phone/Fax

Practice location:
  • Phone: 248-628-1880
  • Fax: 248-628-1881
Mailing address:
  • Phone: 248-628-1880
  • Fax: 248-628-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number5901400128
License Number StateMI

VIII. Authorized Official

Name: DR. BRUCE TABAK
Title or Position: OWNER
Credential: D.P.M.
Phone: 248-628-1880