Provider Demographics
NPI:1093901795
Name:BRUCE TABAK, D.P.M.
Entity Type:Organization
Organization Name:BRUCE TABAK, D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:TABAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-628-1880
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-18
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901400128335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3142556Medicaid