Provider Demographics
NPI:1326058496
Name:TAVAREZ-VALLE, JOSE A (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:A
Last Name:TAVAREZ-VALLE
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:PO BOX 360013
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-0013
Mailing Address - Country:US
Mailing Address - Phone:787-792-3203
Mailing Address - Fax:787-273-6970
Practice Address - Street 1:864 AVE SAN PATRICIO
Practice Address - Street 2:LAS LOMAS
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-1308
Practice Address - Country:US
Practice Address - Phone:787-792-9833
Practice Address - Fax:787-273-6970
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRTRIPLE-SOtherGENERAL PRACTICE
PR0026717Medicare ID - Type UnspecifiedGENERAL PRACTICE