Healthcare Provider Details

I. General information

NPI: 1275894461
Provider Name (Legal Business Name): EVAN MATTHEW TAVAKOLI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 9TH ST
FLORENCE OR
97439-7388
US

IV. Provider business mailing address

75 FRANCIS ST
BOSTON MA
02115-6106
US

V. Phone/Fax

Practice location:
  • Phone: 541-997-7104
  • Fax: 541-997-5975
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number222577
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberDR.0058700
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD225448
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: