Basic Information
| Provider Information | |||||||||
| NPI: | 1407187172 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REDA TADROS, MD, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1633 ERRINGER RD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | SIMI VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930653583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 S 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | BARSTOW | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923113043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055788300 | ||||||||
| FaxNumber: | 8055783911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2010 | ||||||||
| LastUpdateDate: | 01/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | TADROS | ||||||||
| AuthorizedOfficialFirstName: | REDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7602458691 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZC0006X | 05D0573118 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 05D0573118 | 01 | CA | CLIA | OTHER |