Provider Demographics
NPI:1437335999
Name:TAVAREZ, MARIEN (MD)
Entity Type:Individual
Prefix:
First Name:MARIEN
Middle Name:
Last Name:TAVAREZ
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 1:201 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-2949
Mailing Address - Country:US
Mailing Address - Phone:334-794-6611
Mailing Address - Fax:334-794-6614
Practice Address - Street 1:201 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2949
Practice Address - Country:US
Practice Address - Phone:334-794-6611
Practice Address - Fax:334-794-6614
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA235343207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2158078Medicaid
MA2158078Medicaid