Provider Demographics
NPI:1821063181
Name:TAVARES, JOHN PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:TAVARES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2470 GRAY FALLS DR STE 150
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-6525
Mailing Address - Country:US
Mailing Address - Phone:281-556-5353
Mailing Address - Fax:
Practice Address - Street 1:2677 WILCREST DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-3211
Practice Address - Country:US
Practice Address - Phone:713-977-1170
Practice Address - Fax:713-977-3327
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6418TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1690075-01Medicaid
TX1690075-02Medicaid
TX169007504Medicaid
TXU98840Medicare UPIN
TX1690075-02Medicaid
TX8L21850Medicare PIN