Basic Information
| Provider Information | |||||||||
| NPI: | 1750825295 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEPORTO | ||||||||
| FirstName: | TANYA | ||||||||
| MiddleName: | AUDREY MARGARET | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD, PHD, MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GRIFFITHS | ||||||||
| OtherFirstName: | TANYA | ||||||||
| OtherMiddleName: | AUDREY MARGARET | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD, PHD, MPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 315 | ||||||||
| Address2: | |||||||||
| City: | WILDOMAR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925950315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 26001 REDLANDS BLVD | ||||||||
| Address2: | |||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923737762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098257084 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2016 | ||||||||
| LastUpdateDate: | 08/17/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0901X | 145547 | CA | Y | Allopathic & Osteopathic Physicians | Preventive Medicine | Public Health & General Preventive Medicine |
No ID Information.