Provider Demographics
NPI:1508801317
Name:TABASSIAN, MITRA (DPM)
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:
Last Name:TABASSIAN
Suffix:
Gender:F
Credentials:DPM
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 965
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-0965
Mailing Address - Country:US
Mailing Address - Phone:310-671-0004
Mailing Address - Fax:310-330-4557
Practice Address - Street 1:426 E ARBOR VITAE ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-3450
Practice Address - Country:US
Practice Address - Phone:310-671-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE40610213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4061Medicare PIN