Provider Demographics
NPI:1871714279
Name:VIPIN M. TANDON M.D., INC
Entity type:Organization
Organization Name:VIPIN M. TANDON M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:LEAH
Authorized Official - Last Name:LACKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-522-3195
Mailing Address - Street 1:1687 ERRINGER RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1687 ERRINGER RD
Practice Address - Street 2:SUITE 103
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-6508
Practice Address - Country:US
Practice Address - Phone:805-522-3195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA26262261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A262620Medicaid
CAA26262Medicare ID - Type Unspecified
CAA24788Medicare UPIN