Provider Demographics
NPI:1982934709
Name:TABLADA-QUINTANILLA, MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:TABLADA-QUINTANILLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ESPIRITU
Other - Last Name:TABLADA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2530
Mailing Address - Country:US
Mailing Address - Phone:818-500-1331
Mailing Address - Fax:
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2530
Practice Address - Country:US
Practice Address - Phone:818-500-1369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-29
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110098208000000X
NY254690208000000X
TXN8057208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics