Provider Demographics
NPI:1619439213
Name:TAVARES, EMMANUEL JOHN (MD)
Entity Type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:JOHN
Last Name:TAVARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EMMANUELLE
Other - Middle Name:JOHN
Other - Last Name:TAVARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4860 Y ST STE 3500
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4860 Y ST STE 3500
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2307
Practice Address - Country:US
Practice Address - Phone:916-734-2893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program