Provider Demographics
NPI:1841276037
Name:TABOR, BRENT ERIC (DPM)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ERIC
Last Name:TABOR
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 1:702 RUSSELL AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-2606
Mailing Address - Country:US
Mailing Address - Phone:301-948-3668
Mailing Address - Fax:
Practice Address - Street 1:702 RUSSELL AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-2606
Practice Address - Country:US
Practice Address - Phone:301-948-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01195213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD218838400Medicaid
DC087827D98Medicare PIN
MDU50165Medicare UPIN
DC480017420Medicare PIN