MEDICARE: GLORY CABANILLA TANCINCO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207LP3000X	Pediatric Anesthesiology Physician	C50519	CA
2	207L00000X	Anesthesiology Physician	C50519	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1003033754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORY CABANILLA TANCINCO MD

Provider Business Mailing Address
First Line	:	PO BOX 60790
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91116-6790
Country	:	US
Telephone Number	:
Fax Number	:	213-413-0327

Provider Business Practice Location Address
First Line	:	6245 DE LONGPRE AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-8253
Country	:	US
Telephone Number	:	234-622-2713
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	10/17/2019

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