Healthcare Provider Details

I. General information

NPI: 1780645903
Provider Name (Legal Business Name): ALEX RAMON TAVERAS-CRUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264A PALM COAST PKWY NE
PALM COAST FL
32137-8217
US

IV. Provider business mailing address

2460 OLD MOULTRIE RD STE 2
ST AUGUSTINE FL
32086-4198
US

V. Phone/Fax

Practice location:
  • Phone: 386-446-5505
  • Fax: 386-446-5077
Mailing address:
  • Phone: 904-293-0299
  • Fax: 904-797-7417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number15423
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: