Provider Demographics
NPI:1942307764
Name:TABB, WILLIAM H (DPM)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:H
Last Name:TABB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 W BONITA AVE
Mailing Address - Street 2:110
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2541
Mailing Address - Country:US
Mailing Address - Phone:909-599-0981
Mailing Address - Fax:909-592-0738
Practice Address - Street 1:425 W BONITA AVE
Practice Address - Street 2:110
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2541
Practice Address - Country:US
Practice Address - Phone:909-599-0981
Practice Address - Fax:909-592-0738
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE2478213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E24780Medicaid
CAE2478Medicare ID - Type UnspecifiedNHIC
CAT11349Medicare UPIN
CA000E24782Medicare PIN
CAWE2478DMedicare PIN
CA000E24780Medicaid