Provider Demographics
NPI:1689661811
Name:TAZEWELL, CHRISTINE G (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:G
Last Name:TAZEWELL
Suffix:
Gender:F
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:1524 MCHENRY AVE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4500
Mailing Address - Country:US
Mailing Address - Phone:209-575-4700
Mailing Address - Fax:209-577-6699
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-575-4700
Practice Address - Fax:209-577-6699
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG66546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G665460Medicaid
E56232Medicare UPIN
CA00G665460Medicaid