=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255746244
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS ROMAN TAVERAS MORALES M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2014
-----------------------------------------------------
Last Update Date | 09/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 MEDICAL CENTER DR STE 205
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75069-1650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-547-8000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 W 15TH ST STE 340
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-202-7080
-----------------------------------------------------
Fax | 972-202-7085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | T2993
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------