Healthcare Provider Details

I. General information

NPI: 1205285665
Provider Name (Legal Business Name): GEVORK GRIKOR TATARIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 10 6000 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-1001
US

IV. Provider business mailing address

6917 COLLINS AVE APT 726
MIAMI BEACH FL
33141-7203
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME149214
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: