Provider Demographics
NPI:1336128842
Name:TANNEBAUM, IRA ROY (MD)
Entity Type:Individual
Prefix:
First Name:IRA
Middle Name:ROY
Last Name:TANNEBAUM
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 1:8624 WILD OLIVE DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3438
Mailing Address - Country:US
Mailing Address - Phone:301-251-0099
Mailing Address - Fax:301-251-4197
Practice Address - Street 1:1145 19TH ST NW
Practice Address - Street 2:313
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-3701
Practice Address - Country:US
Practice Address - Phone:202-466-5837
Practice Address - Fax:202-466-5773
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD10031208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
105613Medicare ID - Type Unspecified
B93396Medicare UPIN