Provider Demographics
NPI:1689787848
Name:TAIVAL, TANYA ITANI (DO LLC)
Entity Type:Individual
Prefix:DR
First Name:TANYA
Middle Name:ITANI
Last Name:TAIVAL
Suffix:
Gender:F
Credentials:DO LLC
Other - Prefix:DR
Other - First Name:TANYA
Other - Middle Name:ITANI
Other - Last Name:TAIVAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO LLC
Mailing Address - Street 1:875 CENTURY MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2142
Mailing Address - Country:US
Mailing Address - Phone:321-269-0748
Mailing Address - Fax:321-383-2424
Practice Address - Street 1:875 CENTURY MEDICAL DR
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2142
Practice Address - Country:US
Practice Address - Phone:321-269-0748
Practice Address - Fax:321-383-2424
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-15
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 9527207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272865600Medicaid
FL0256154OtherCIGNA
FL7840697OtherAETNA
FL14016OtherBLUE CROSS/BLUE SHIELD
FLP00240993OtherMEDICARE RAILROAD
FL14016OtherBLUE CROSS/BLUE SHIELD
FL14016ZMedicare ID - Type UnspecifiedMEDICARE