Healthcare Provider Details

I. General information

NPI: 1861590663
Provider Name (Legal Business Name): RICHARD J TABERSHAW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 EAST MAIN STREET SUITE 1
BAYSHORE NY
11706
US

IV. Provider business mailing address

375 EAST MAIN STREET SUITE 1
BAYSHORE NY
11706
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-8790
  • Fax: 631-665-1581
Mailing address:
  • Phone: 631-665-8790
  • Fax: 631-665-1581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number148855
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: