Provider Demographics
NPI:1225036742
Name:IJAZ, TAHIR (MD)
Entity Type:Individual
Prefix:DR
First Name:TAHIR
Middle Name:
Last Name:IJAZ
Suffix:
Gender:M
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:PO BOX 33865
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-3865
Mailing Address - Country:US
Mailing Address - Phone:858-888-7700
Mailing Address - Fax:858-888-7721
Practice Address - Street 1:3366 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-5713
Practice Address - Country:US
Practice Address - Phone:619-230-0400
Practice Address - Fax:858-429-7936
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52748174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A527480Medicaid
CAA52748OtherSTATE LICENSE
CAA52748OtherSTATE LICENSE
CAWA52748FMedicare PIN
CAWA52448CMedicare PIN
CAB15450589OtherDEA CERTIFICATE
CACR611YMedicare PIN
CAG58582Medicare UPIN
CAWA52748BMedicare PIN
CA00A527480Medicaid
CAWA52748EMedicare PIN