Provider Demographics
NPI:1922043017
Name:TAZANU, ABILA VIOLET (MD)
Entity Type:Individual
Prefix:
First Name:ABILA
Middle Name:VIOLET
Last Name:TAZANU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ABILA
Other - Middle Name:VIOLET
Other - Last Name:TAZANU-LEGALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:7401 FORBES BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LANHAM
Mailing Address - State:MD
Mailing Address - Zip Code:20706-2288
Mailing Address - Country:US
Mailing Address - Phone:301-618-8395
Mailing Address - Fax:301-618-8396
Practice Address - Street 1:7401 FORBES BLVD STE A
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2288
Practice Address - Country:US
Practice Address - Phone:301-618-8395
Practice Address - Fax:301-618-8396
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCCS1100020208000000X
MDD0055053208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD685801500Medicaid
MD013856B82Medicare ID - Type Unspecified
MD685801500Medicaid