Provider Demographics
NPI:1619921426
Name:PREVOST, SAIRWAA TANDEE (MD)
Entity Type:Individual
Prefix:DR
First Name:SAIRWAA
Middle Name:TANDEE
Last Name:PREVOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:TANDEE
Other - Middle Name:BELINDA
Other - Last Name:PREVOST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5447 WHITE OAK AVE
Mailing Address - Street 2:#303
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-4500
Mailing Address - Country:US
Mailing Address - Phone:818-343-5820
Mailing Address - Fax:818-343-5820
Practice Address - Street 1:433 N. 4TH STREET
Practice Address - Street 2:SUITE 216
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640
Practice Address - Country:US
Practice Address - Phone:323-869-0000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51315207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG42886Medicare UPIN