Provider Demographics
NPI:1275775470
Name:TAVLAN, ANDREA CHARLENE (MD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:CHARLENE
Last Name:TAVLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 WESTFIELD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-1163
Mailing Address - Country:US
Mailing Address - Phone:203-734-1644
Mailing Address - Fax:203-734-9222
Practice Address - Street 1:20 WESTFIELD AVENUE
Practice Address - Street 2:
Practice Address - City:ANSONIA
Practice Address - State:CT
Practice Address - Zip Code:06401-1163
Practice Address - Country:US
Practice Address - Phone:203-734-1644
Practice Address - Fax:203-734-9222
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263861208000000X
CT53394208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics