Provider Demographics
NPI:1922010420
Name:TABANERA, PABLITO A (MD)
Entity Type:Individual
Prefix:
First Name:PABLITO
Middle Name:A
Last Name:TABANERA
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 1:620 BROAD ST
Mailing Address - Street 2:CENTRAL STATE HOSPITAL
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31062-7525
Mailing Address - Country:US
Mailing Address - Phone:478-445-4128
Mailing Address - Fax:
Practice Address - Street 1:620 BROAD ST
Practice Address - Street 2:CENTRAL STATE HOSPITAL
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31062-7525
Practice Address - Country:US
Practice Address - Phone:478-445-4128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA022062207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA22BDCBRMedicare ID - Type Unspecified
GAF13626Medicare UPIN
GA00593392AMedicare ID - Type Unspecified