Provider Demographics
NPI:1457477226
Name:TAVLARIDES, DESPINA M (DO)
Entity Type:Individual
Prefix:
First Name:DESPINA
Middle Name:M
Last Name:TAVLARIDES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:DESPINA
Other - Middle Name:TAVLARIDES
Other - Last Name:HERRERA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:BANNER HEALTH CLINIC
Mailing Address - Street 2:4530 E. RAY RD. SUITE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044
Mailing Address - Country:US
Mailing Address - Phone:480-827-5420
Mailing Address - Fax:480-890-2997
Practice Address - Street 1:4530 E. RAY RD. SUITE 150
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044
Practice Address - Country:US
Practice Address - Phone:480-827-5420
Practice Address - Fax:480-877-5426
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ127723Medicare PIN
Z123950Medicare PIN