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Individual
TATIANA MARIE MAMANTOV
Active
Individual
TATIANA MARIE MAMANTOV
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
G85179
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00G851790
BLUE SHIELD
CA
05
—
00G851790
—
CA
Enumeration date
11/03/2005
Last updated
07/30/2008
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