Provider Demographics
NPI:1629092473
Name:DAVID, TAL (MD)
Entity Type:Individual
Prefix:
First Name:TAL
Middle Name:
Last Name:DAVID
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TAL
Other - Middle Name:SAMUEL
Other - Last Name:DAVID
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4445 EASTGATE MALL STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-1979
Mailing Address - Country:US
Mailing Address - Phone:858-412-6080
Mailing Address - Fax:858-412-6376
Practice Address - Street 1:4910 DIRECTORS PL STE 350
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3834
Practice Address - Country:US
Practice Address - Phone:858-571-9500
Practice Address - Fax:858-453-7314
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA69504207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W17895OtherMEDICARE GROUP NUMBER
W17895OtherMEDICARE PTAN
WA69504COtherMEDICARE PROVIDER ID
H03615Medicare UPIN