Healthcare Provider Details

I. General information

NPI: 1518049865
Provider Name (Legal Business Name): MARINO D TAVAREZ M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 LEACH RD LYONS HEALTH CENTER
LYONS NY
14489-9732
US

IV. Provider business mailing address

12 LEACH RD LYONS HEALTH CENTER
LYONS NY
14489-9732
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-6075
  • Fax: 315-946-4254
Mailing address:
  • Phone: 315-946-6075
  • Fax: 315-946-4254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number232852
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD441558
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12860
License Number StateHI
# 4
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number232852
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberMD441558
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number12860
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: