Provider Demographics
NPI:1407408826
Name:TAVAREZ RODRIGUEZ, SARA ALTAGRACIA (MD)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:ALTAGRACIA
Last Name:TAVAREZ RODRIGUEZ
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 1:357 EDGECOMBE AVE APT 1E
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10031-1303
Mailing Address - Country:US
Mailing Address - Phone:347-356-7588
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTCHESTER AVE STE 302
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-5071
Practice Address - Country:US
Practice Address - Phone:718-829-1900
Practice Address - Fax:718-892-5640
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY317699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid