Provider Demographics
NPI:1902115793
Name:TAMBELLINI, MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:TAMBELLINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 BROWER CT
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-6742
Mailing Address - Country:US
Mailing Address - Phone:916-761-9399
Mailing Address - Fax:916-774-4360
Practice Address - Street 1:5021 BROWER CT
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-6742
Practice Address - Country:US
Practice Address - Phone:916-761-9399
Practice Address - Fax:916-774-4360
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG37599207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG37599OtherMEDICAL BOARD OF CALIFORNIA