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Individual
TACKSON TAM
Active
Individual
TACKSON TAM
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
G70073
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
110200071
RAIL ROAD MEDICARE - PROVIDER PTAN
CA
01
—
1912919804
MEDI-CAL
CA
01
—
CG5665
RAIL ROAD MEDICARE - GROUP PTAN
CA
01
—
W1514
MEDICARE PTAN - TYPE 2
CA
Enumeration date
03/14/2006
Last updated
11/11/2021
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