Provider Demographics
NPI:1457367179
Name:TAGLE, AMANDA (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:TAGLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:7215 55TH STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2601
Practice Address - Country:US
Practice Address - Phone:916-399-1100
Practice Address - Fax:877-860-2397
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60188208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01288574/ DS9933OtherRAILROAD MEDICARE- 55TH ST
CA00A601880OtherMEDI CAL
CAP01453275-DV5277OtherRAILROAD MEDICARE
CA00A601880Medicaid
CA00A601880Medicaid
CACA140803Medicare PIN
CA00A601883Medicare PIN
H29018Medicare UPIN
CA00A601884Medicare PIN
CAP01288574/ DS9933OtherRAILROAD MEDICARE- 55TH ST
CAGD583ZMedicare PIN
CA00A601885Medicare PIN
CA00A601880Medicare PIN