Healthcare Provider Details

I. General information

NPI: 1821766502
Provider Name (Legal Business Name): IVAN APONTE TABOAS MD STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 06/13/2023
Certification Date: 06/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2545 SCHOENERSVILLE RD
BETHLEHEM PA
18017-7300
US

IV. Provider business mailing address

340 CALLE GONZALO BERCEO URB EL SENORIAL
SAN JUAN PR
00926
US

V. Phone/Fax

Practice location:
  • Phone: 484-884-2489
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMT229475
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: