MEDICARE: TARA ZANDVLIET M.D.

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	A71646	CA

General Provider Information

NPI Number	:	1821020157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TARA ZANDVLIET M.D.

Provider Business Mailing Address
First Line	:	5694 MISSION CENTER RD # 602-362
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-4355
Country	:	US
Telephone Number	:	619-929-0032
Fax Number	:	208-728-8168

Provider Business Practice Location Address
First Line	:	2525 CAMINO DEL RIO SOUTH
Second Line	:	SUITE 130, ROOM 3
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3718
Country	:	US
Telephone Number	:	619-929-0032
Fax Number	:	208-728-8168

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

Provider Enumeration Date	:	07/07/2006
Last Update Date	:	05/16/2023

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