Provider Demographics
NPI:1609878289
Name:TABER, MINDY TATERA (MD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:TATERA
Last Name:TABER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5620 W THUNDERBIRD RD
Mailing Address - Street 2:F1
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-4636
Mailing Address - Country:US
Mailing Address - Phone:602-938-6960
Mailing Address - Fax:602-938-6069
Practice Address - Street 1:9150 W INDIAN SCHOOL RD
Practice Address - Street 2:SUITE 118
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-2384
Practice Address - Country:US
Practice Address - Phone:602-938-6960
Practice Address - Fax:602-938-6069
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32919207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ960858001Medicaid
AZZWCGBRMedicare PIN
AZCD5921Medicare PIN