Provider Demographics
NPI:1588627244
Name:TABOR, ERIC NEAL (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:NEAL
Last Name:TABOR
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 1:2780 GAUSE BLVD E
Mailing Address - Street 2:SUITE A
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70461-4149
Mailing Address - Country:US
Mailing Address - Phone:985-641-5198
Mailing Address - Fax:985-641-5398
Practice Address - Street 1:2780 GAUSE BLVD E
Practice Address - Street 2:SUITE A
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4149
Practice Address - Country:US
Practice Address - Phone:985-641-5198
Practice Address - Fax:985-641-5398
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12278R207N00000X
MS15605207N00000X
CAG81348207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1695149Medicaid
MS00119852Medicaid
LA5Y493CU52Medicare PIN
LAG47495Medicare UPIN
MSC02746Medicare PIN