Healthcare Provider Details

I. General information

NPI: 1881604601
Provider Name (Legal Business Name): TOMAS HAVRANEK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/13/2023
Certification Date: 09/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 TENBROECK AVE
BRONX NY
10461-2007
US

IV. Provider business mailing address

1601 TENBROECK AVE
BRONX NY
10461-2007
US

V. Phone/Fax

Practice location:
  • Phone: 314-440-9242
  • Fax:
Mailing address:
  • Phone: 314-440-9242
  • Fax: 317-977-6777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2006034636
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number2006034636
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number216275
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: