Provider Demographics
NPI:1629159876
Name:JAMIL, TARIQ
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:
Last Name:JAMIL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6983
Mailing Address - Country:US
Mailing Address - Phone:909-883-3838
Mailing Address - Fax:
Practice Address - Street 1:399 E HIGHLAND AVE
Practice Address - Street 2:SUITE 502
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3808
Practice Address - Country:US
Practice Address - Phone:909-883-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70628174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A706280Medicaid
CABJ6709577OtherDEA NUMBER
CA00A706280Medicare PIN
CABJ6709577OtherDEA NUMBER