Provider Demographics
NPI:1063456028
Name:AMADOR TAVAREZ, JUAN A (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:A
Last Name:AMADOR TAVAREZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-4924
Mailing Address - Country:US
Mailing Address - Phone:727-869-7755
Mailing Address - Fax:727-869-7372
Practice Address - Street 1:8501 LITTLE RD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-4924
Practice Address - Country:US
Practice Address - Phone:727-869-7755
Practice Address - Fax:727-869-7372
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR14474207Q00000X
FLME132750207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRH93182Medicare UPIN
PR21660Medicare ID - Type Unspecified