MEDICARE: H. SPRAGUE TAVEAU IV DO PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	J0696	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306930250
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	H. SPRAGUE TAVEAU IV DO PA

Provider Business Mailing Address
First Line	:	2300 S CLEAR CREEK RD
Second Line	:	SUITE 101
City	:	KILLEEN
State	:	TX
Zip	:	76549-4984
Country	:	US
Telephone Number	:	855-963-4325
Fax Number	:	855-963-4325

Provider Business Practice Location Address
First Line	:	2300 S CLEAR CREEK RD
Second Line	:	SUITE 101
City	:	KILLEEN
State	:	TX
Zip	:	76549-4984
Country	:	US
Telephone Number	:	855-963-4325
Fax Number	:	855-963-4325

Authorized Official
Title or Position	:	OWNER
Name	:	HORATIO SPRAGUE TAVEAU IV
Credential	:	DO
Telephone Number	:	855-963-4325

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	05/16/2014

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Directions to “H. SPRAGUE TAVEAU IV DO PA ” Practice Location

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