Provider Demographics
NPI:1184669988
Name:FROMLAK, TATIANA I (MD)
Entity Type:Individual
Prefix:DR
First Name:TATIANA
Middle Name:I
Last Name:FROMLAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 N SUNRISE AVE STE 240
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2847
Mailing Address - Country:US
Mailing Address - Phone:916-782-1717
Mailing Address - Fax:916-782-5270
Practice Address - Street 1:576 N SUNRISE AVE STE 240
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2847
Practice Address - Country:US
Practice Address - Phone:916-782-1717
Practice Address - Fax:916-782-5270
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92829174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAI 21532Medicare UPIN