Provider Demographics
NPI:1154056703
Name:ZERBO, TIDIANE IDABO
Entity Type:Individual
Prefix:
First Name:TIDIANE
Middle Name:IDABO
Last Name:ZERBO
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 1:610 ROLLINS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4112
Mailing Address - Country:US
Mailing Address - Phone:240-381-3066
Mailing Address - Fax:
Practice Address - Street 1:610 ROLLINS AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4112
Practice Address - Country:US
Practice Address - Phone:240-381-3066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-18
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019008292225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty