Provider Demographics
NPI:1083897086
Name:TAVEAU, JON WILLIAM
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:WILLIAM
Last Name:TAVEAU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 CLINCHFIELD ST STE 103
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3859
Mailing Address - Country:US
Mailing Address - Phone:423-578-1518
Mailing Address - Fax:423-230-6349
Practice Address - Street 1:444 CLINCHFIELD ST STE 103
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3859
Practice Address - Country:US
Practice Address - Phone:423-578-1518
Practice Address - Fax:423-230-6349
Is Sole Proprietor?:No
Enumeration Date:2007-12-12
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.123122207T00000X
CA20A9091207T00000X
TN3367207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ038189Medicaid
IL036123122Medicaid
IL3932056OtherBCBS
IL721089OtherAETNA
IL036123122Medicaid
IL214881Medicare Oscar/Certification