Healthcare Provider Details

I. General information

NPI: 1396083630
Provider Name (Legal Business Name): JOSE TAVAREZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8430 ENTERPRISE CIR STE 130
LAKEWOOD RANCH FL
34202-4111
US

IV. Provider business mailing address

PO BOX 863407
ORLANDO FL
32886-3407
US

V. Phone/Fax

Practice location:
  • Phone: 941-366-3000
  • Fax: 941-366-3002
Mailing address:
  • Phone: 941-917-2600
  • Fax: 941-917-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22828
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME130063
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: