Healthcare Provider Details

I. General information

NPI: 1356861496
Provider Name (Legal Business Name): JAVIER ALCID DURON TABORA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 07/08/2022
Certification Date: 07/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 PARK ST
BOWLING GREEN KY
42101-1742
US

IV. Provider business mailing address

201 PARK ST
BOWLING GREEN KY
42101-1708
US

V. Phone/Fax

Practice location:
  • Phone: 270-783-3362
  • Fax:
Mailing address:
  • Phone: 270-781-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number036.153095
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number56700
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: