Healthcare Provider Details

I. General information

NPI: 1679776645
Provider Name (Legal Business Name): LUIS ANGEL TABOADA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

833 CHESTNUT STREET SUITE 701
PHILADELPHIA PA
19107-4414
US

IV. Provider business mailing address

833 CHESTNUT STREET SUITE 701
PHILADELPHIA PA
19107-4414
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6180
  • Fax: 215-955-6410
Mailing address:
  • Phone: 215-955-6180
  • Fax: 215-955-6410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT190941
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD439596
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: