Healthcare Provider Details

I. General information

NPI: 1750389755
Provider Name (Legal Business Name): MATTHEW J. TAVROFF D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8475 MAIN ST
BRIARWOOD NY
11435-1624
US

IV. Provider business mailing address

8475 MAIN ST
BRIARWOOD NY
11435-1624
US

V. Phone/Fax

Practice location:
  • Phone: 718-657-8921
  • Fax: 718-657-9650
Mailing address:
  • Phone: 718-657-8921
  • Fax: 718-657-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN005112
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: