Provider Demographics
NPI:1821020157
Name:ZANDVLIET, TARA (MD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:ZANDVLIET
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 1:5694 MISSION CENTER RD # 602-362
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4355
Mailing Address - Country:US
Mailing Address - Phone:619-929-0032
Mailing Address - Fax:208-728-8168
Practice Address - Street 1:2525 CAMINO DEL RIO SOUTH
Practice Address - Street 2:SUITE 130, ROOM 3
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3718
Practice Address - Country:US
Practice Address - Phone:619-929-0032
Practice Address - Fax:208-728-8168
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA71646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics