Provider Demographics
NPI:1457732612
Name:GRODIN, TABATA BAHIENSE (MD)
Entity Type:Individual
Prefix:
First Name:TABATA
Middle Name:BAHIENSE
Last Name:GRODIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TABATA
Other - Middle Name:
Other - Last Name:BAHIENSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2800 S SEACREST BLVD STE 220
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33435-7965
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2800 S SEACREST BLVD STE 220
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33435-7965
Practice Address - Country:US
Practice Address - Phone:561-413-2850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-13
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME138810207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology