MEDICARE: IRMGARD UNA TACKIE 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	208000000X	Pediatrics Physician	A118539	CA

General Provider Information

NPI Number	:	1215168653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRMGARD UNA TACKIE MD

Provider Business Mailing Address
First Line	:	16096 PITZER ST
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-4530
Country	:	US
Telephone Number	:	865-591-1988
Fax Number	:

Provider Business Practice Location Address
First Line	:	15290 SUMMIT AVE
Second Line	:	SUITE B
City	:	FONTANA
State	:	CA
Zip	:	92336-0240
Country	:	US
Telephone Number	:	909-225-1900
Fax Number	:

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

Provider Enumeration Date	:	08/03/2009
Last Update Date	:	12/08/2021

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