Provider Demographics
NPI:1609993542
Name:TAVERAS MD, PC
Entity Type:Organization
Organization Name:TAVERAS MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FERNADO
Authorized Official - Middle Name:T
Authorized Official - Last Name:TAVERAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-568-1838
Mailing Address - Street 1:659 W 179TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10033-5735
Mailing Address - Country:US
Mailing Address - Phone:212-568-1838
Mailing Address - Fax:212-740-5163
Practice Address - Street 1:659 W 179TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-5735
Practice Address - Country:US
Practice Address - Phone:212-568-1838
Practice Address - Fax:212-740-5163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226618207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02365548Medicaid
NY=========OtherTAX ID