Provider Demographics
NPI:1649296146
Name:TANZO, VENUS EUGENIO
Entity type:Individual
Prefix:
First Name:VENUS
Middle Name:EUGENIO
Last Name:TANZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:498 W 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2070
Mailing Address - Country:US
Mailing Address - Phone:951-943-8899
Mailing Address - Fax:951-943-4598
Practice Address - Street 1:498 W 4TH ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2070
Practice Address - Country:US
Practice Address - Phone:951-943-8899
Practice Address - Fax:951-943-4598
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51018208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC70593FMedicaid
CAFHC70593FMedicaid
CA551903Medicare Oscar/Certification