Provider Demographics
NPI:1053401802
Name:TAHL, MARIANNE (MD)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
Last Name:TAHL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2390 E FLORIDA AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544
Mailing Address - Country:US
Mailing Address - Phone:951-658-7297
Mailing Address - Fax:951-925-6774
Practice Address - Street 1:2390 E FLORIDA AVE
Practice Address - Street 2:SUITE #101
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544
Practice Address - Country:US
Practice Address - Phone:951-658-7297
Practice Address - Fax:951-925-6774
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA22279207K00000X, 207Q00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA86502Medicare UPIN