Provider Demographics
NPI:1356728760
Name:TABATABAI, NILOOFAR (LAC OMD)
Entity type:Individual
Prefix:DR
First Name:NILOOFAR
Middle Name:
Last Name:TABATABAI
Suffix:
Gender:F
Credentials:LAC OMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 DOVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2432
Mailing Address - Country:US
Mailing Address - Phone:949-502-3388
Mailing Address - Fax:949-502-3304
Practice Address - Street 1:1600 DOVE ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2432
Practice Address - Country:US
Practice Address - Phone:949-502-3388
Practice Address - Fax:949-502-3304
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-05
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC2962171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist