Provider Demographics
NPI:1093803280
Name:TANCINCO, PABLITO A
Entity Type:Individual
Prefix:
First Name:PABLITO
Middle Name:A
Last Name:TANCINCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 W TEMPLE ST
Mailing Address - Street 2:SUITE 4689
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-5421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1711 W TEMPLE ST
Practice Address - Street 2:SUITE 4689
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5421
Practice Address - Country:US
Practice Address - Phone:213-413-2280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C426610207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C426610Medicaid
CA00C426610Medicaid
CAC42661Medicare ID - Type UnspecifiedMEDICARE