Provider Demographics
NPI:1770587404
Name:TABBERT, WILLIAM G (DPM)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:G
Last Name:TABBERT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 ELLEN KAY DR
Mailing Address - Street 2:STE E
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6358
Mailing Address - Country:US
Mailing Address - Phone:740-387-2274
Mailing Address - Fax:740-382-0600
Practice Address - Street 1:1125 ELLEN KAY DR
Practice Address - Street 2:STE E
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6358
Practice Address - Country:US
Practice Address - Phone:740-387-2274
Practice Address - Fax:740-382-0600
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2008-05-29
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-03-21
Provider Licenses
StateLicense IDTaxonomies
OH2025213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000118247OtherANTHEM BLUE CROSS
OH0464831Medicaid
OH0594240001Medicare NSC
OH000000118247OtherANTHEM BLUE CROSS
OHT80154Medicare UPIN
OH480000683Medicare ID - Type UnspecifiedMEDICARE/RAILROAD
OH0499615Medicare ID - Type UnspecifiedMEDICARE - MT. GILEAD