Provider Demographics
NPI:1548267305
Name:TAMBOLI, ARDESHIR T (MD)
Entity type:Individual
Prefix:
First Name:ARDESHIR
Middle Name:T
Last Name:TAMBOLI
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 1:899 E IRON AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2097
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2814 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-3719
Practice Address - Country:US
Practice Address - Phone:304-723-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV12254207K00000X
PAMD036753L207K00000X
OH35045162T207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0433294Medicaid
OHP00469048OtherRR MEDICARE
WV0112183000Medicaid
PA101974726003Medicaid
OH0511968Medicare PIN
OHP00469048OtherRR MEDICARE
WV0112183000Medicaid
PA101974726003Medicaid