MEDICARE: DR. MEHRAN RYAN TAVAKOLI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME 96484	FL

General Provider Information

NPI Number	:	1841294394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MEHRAN RYAN TAVAKOLI MD

Provider Business Mailing Address
First Line	:	4902 NE 139TH ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98686-2292
Country	:	US
Telephone Number	:	850-273-0442
Fax Number	:

Provider Business Practice Location Address
First Line	:	8383 N DAVIS HWY
Second Line	:
City	:	PENSACOLA
State	:	FL
Zip	:	32514-6039
Country	:	US
Telephone Number	:	850-494-6495
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	03/03/2010

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