Healthcare Provider Details

I. General information

NPI: 1982973582
Provider Name (Legal Business Name): MEL CLARK REQUIAS TAVEROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 BRUNDAGE LN
BAKERSFIELD CA
93304-3248
US

IV. Provider business mailing address

PO BOX 1559
BAKERSFIELD CA
93302-1559
US

V. Phone/Fax

Practice location:
  • Phone: 661-323-6086
  • Fax: 661-324-6301
Mailing address:
  • Phone: 661-635-3050
  • Fax: 661-635-3070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA139158
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: