Healthcare Provider Details

I. General information

NPI: 1427542711
Provider Name (Legal Business Name): ANDREW PIMENTA TAVARES MD, MSC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2018
Last Update Date: 12/04/2021
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

121 DEKALB AVE
BROOKLYN NY
11201-5425
US

V. Phone/Fax

Practice location:
  • Phone: 410-328-8667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101273279
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: