Provider Demographics
NPI:1225615818
Name:TABBOGA, ZILDJIAN
Entity Type:Individual
Prefix:
First Name:ZILDJIAN
Middle Name:
Last Name:TABBOGA
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 1:1715 QUEENS CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95132-1762
Mailing Address - Country:US
Mailing Address - Phone:408-477-6809
Mailing Address - Fax:
Practice Address - Street 1:1715 QUEENS CROSSING DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95132-1762
Practice Address - Country:US
Practice Address - Phone:408-477-6809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator