Provider Demographics
NPI:1053399162
Name:ZEBALLOS, TATIANA M (MD)
Entity type:Individual
Prefix:
First Name:TATIANA
Middle Name:M
Last Name:ZEBALLOS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 VIA ARCO
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-2055
Mailing Address - Country:US
Mailing Address - Phone:202-285-4550
Mailing Address - Fax:
Practice Address - Street 1:1408 VIA ARCO
Practice Address - Street 2:
Practice Address - City:PALOS VERDES ESTATES
Practice Address - State:CA
Practice Address - Zip Code:90274-2055
Practice Address - Country:US
Practice Address - Phone:202-285-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425510208000000X
FLME127937208000000X
CAC1644472083B0002X, 2080B0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080B0002XAllopathic & Osteopathic PhysiciansPediatricsObesity Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC164447OtherMEDICAL LICENSE
MDD0083136OtherMEDICAL LICENSE
NJ25MA10057100OtherMEDICAL LICENSE
FL019048000Medicaid
GA78664OtherMEDICAL LICENSE
DEC1-0011945OtherMEDICAL LICENSE
PAMD425510OtherLICENSE