Provider Demographics
NPI:1619131398
Name:TACLOB, MICHELLE MARIA (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MARIA
Last Name:TACLOB
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 1:100 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07505-1024
Mailing Address - Country:US
Mailing Address - Phone:973-523-0317
Mailing Address - Fax:
Practice Address - Street 1:100 MAIN ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07505-1024
Practice Address - Country:US
Practice Address - Phone:973-523-0317
Practice Address - Fax:973-684-8590
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09036900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA09036900OtherMEDICAL LICENSE