Healthcare Provider Details

I. General information

NPI: 1366409906
Provider Name (Legal Business Name): TANVIR M DARA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 S MAIN ST STE 270
JAMESTOWN NY
14701-6629
US

IV. Provider business mailing address

4475 WEST VILLAGE PARKWAY
ELLENWOOD GA
30294-2634
US

V. Phone/Fax

Practice location:
  • Phone: 716-489-3144
  • Fax: 716-489-3152
Mailing address:
  • Phone: 561-998-8889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number197036
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number197036
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: