Provider Demographics
NPI:1225579006
Name:LG AGUILAR TABORA, MD INC
Entity Type:Organization
Organization Name:LG AGUILAR TABORA, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LESLY
Authorized Official - Middle Name:GISELLE
Authorized Official - Last Name:AGUILAR TABORA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-252-8655
Mailing Address - Street 1:PO BOX 928684
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92192-8684
Mailing Address - Country:US
Mailing Address - Phone:858-252-8655
Mailing Address - Fax:619-930-9022
Practice Address - Street 1:8650 GENESSEE AVE. STE 214
Practice Address - Street 2:#8684
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92192-8684
Practice Address - Country:US
Practice Address - Phone:858-252-8655
Practice Address - Fax:619-930-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1069802084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPENDINGOtherPENDING MEDICARE