Provider Demographics
NPI:1831232784
Name:ANTONIO R TANPOCO, MD, INC
Entity type:Organization
Organization Name:ANTONIO R TANPOCO, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:R
Authorized Official - Last Name:TANPOCO
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:707-554-0772
Mailing Address - Street 1:1460 N CAMINO ALTO
Mailing Address - Street 2:SUITE 209
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2567
Mailing Address - Country:US
Mailing Address - Phone:707-554-0772
Mailing Address - Fax:707-554-8323
Practice Address - Street 1:1460 N CAMINO ALTO
Practice Address - Street 2:SUITE 209
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2567
Practice Address - Country:US
Practice Address - Phone:707-554-0772
Practice Address - Fax:707-554-8323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00C508220207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C508220Medicaid
CAZZZ28109ZOtherMEDICARE ID
CAZZZ28109ZOtherMEDICARE ID
CA00C508220Medicaid