Provider Demographics
NPI:1003988577
Name:TABAK, BRUCE (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:TABAK
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-4981
Mailing Address - Country:US
Mailing Address - Phone:248-628-1880
Mailing Address - Fax:248-628-1881
Practice Address - Street 1:129 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-4981
Practice Address - Country:US
Practice Address - Phone:248-628-1880
Practice Address - Fax:248-628-1881
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400128213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1648173Medicaid
MI3142556Medicaid
MI5635090OtherBLUE CROSS OF MICHIGAN
T34146Medicare UPIN
MI1648173Medicaid
0292210001Medicare NSC