Healthcare Provider Details

I. General information

NPI: 1710882790
Provider Name (Legal Business Name): THEODOSIOUS GEORGE TAVRIDES II STUDENT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ALGOMA BLVD
OSHKOSH WI
54901-3551
US

IV. Provider business mailing address

300 W PAPERMILL RUN UNIT 209
KIMBERLY WI
54136-5507
US

V. Phone/Fax

Practice location:
  • Phone: 920-424-1234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: