Provider Demographics
NPI:1871504902
Name:TABAKIAN, HAGOP M (MD)
Entity Type:Individual
Prefix:
First Name:HAGOP
Middle Name:M
Last Name:TABAKIAN
Suffix:
Gender:M
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:PO BOX 44008
Mailing Address - Street 2:UFJP PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:904-244-1740
Practice Address - Street 1:655 W 8TH ST
Practice Address - Street 2:UFJP ANESTHESIA
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6511
Practice Address - Country:US
Practice Address - Phone:904-383-1020
Practice Address - Fax:904-244-1740
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105147207L00000X, 207LP2900X
FLME106558207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0024331-00Medicaid
GA531041563AMedicaid
FLEG094ZMedicare PIN