Provider Demographics
NPI:1669751855
Name:FABIANO, TINA (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:FABIANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3050 SAINT JAMES DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-3369
Mailing Address - Country:US
Mailing Address - Phone:847-308-2975
Mailing Address - Fax:
Practice Address - Street 1:1901 S CONGRESS AVE STE 420
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6588
Practice Address - Country:US
Practice Address - Phone:561-364-1479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-05
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.134175207R00000X, 207R00000X
FLOS14846207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1669751855OtherBCBSWI
WIK400164125 000054176Medicare PIN
WI1669751855Medicaid
WI1669751855OtherBCBSWI
WIK400164125 000054176Medicare PIN