Provider Demographics
NPI:1487763009
Name:DABO, TARAM MBAITOUBAM (MD)
Entity type:Individual
Prefix:DR
First Name:TARAM
Middle Name:MBAITOUBAM
Last Name:DABO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1919 GRAND AVE STE 1E
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4578
Mailing Address - Country:US
Mailing Address - Phone:858-270-5454
Mailing Address - Fax:858-270-5509
Practice Address - Street 1:1919 GRAND AVE STE 1E
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4578
Practice Address - Country:US
Practice Address - Phone:858-270-5454
Practice Address - Fax:858-270-5509
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH69722Medicare UPIN