Provider Demographics
NPI:1891967246
Name:TAMAZOVA, INGA
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:
Last Name:TAMAZOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4855 SANTA MONICA BLVD
Mailing Address - Street 2:114
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-2654
Mailing Address - Country:US
Mailing Address - Phone:323-906-9090
Mailing Address - Fax:323-906-9696
Practice Address - Street 1:4855 SANTA MONICA BLVD
Practice Address - Street 2:114
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2654
Practice Address - Country:US
Practice Address - Phone:323-906-9090
Practice Address - Fax:323-906-9696
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA058101251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA058101Medicare Oscar/Certification