Provider Demographics
NPI:1518049865
Name:TAVAREZ, MARINO D (MD,)
Entity Type:Individual
Prefix:
First Name:MARINO
Middle Name:D
Last Name:TAVAREZ
Suffix:
Gender:M
Credentials:MD,
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Mailing Address - Street 1:12 LEACH RD
Mailing Address - Street 2:LYONS HEALTH CENTER
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-9732
Mailing Address - Country:US
Mailing Address - Phone:315-946-6075
Mailing Address - Fax:315-946-4254
Practice Address - Street 1:12 LEACH RD
Practice Address - Street 2:LYONS HEALTH CENTER
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-9732
Practice Address - Country:US
Practice Address - Phone:315-946-6075
Practice Address - Fax:315-946-4254
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-01-05
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Provider Licenses
StateLicense IDTaxonomies
NY232852207Q00000X, 2083P0901X
PAMD441558207Q00000X, 2083P0901X
HI12860207Q00000X, 2083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02868248Medicaid
NYI49841Medicare UPIN
NY02868248Medicaid