Provider Demographics
NPI:1235376963
Name:TAVAREZ GONZALEZ, JAIME J (MD)
Entity Type:Individual
Prefix:DR
First Name:JAIME
Middle Name:J
Last Name:TAVAREZ GONZALEZ
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 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1223 GATEWAY DR
Practice Address - Street 2:SUITE 1B
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3323
Practice Address - Fax:321-409-3685
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-16
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116253207R00000X, 207R00000X
NY253380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009421600Medicaid
FLP01317002OtherRR MEDICARE
FLHN600YOtherMEDICARE
FLHN600YOtherMEDICARE