Provider Demographics
NPI:1942389317
Name:TANOVIC, MAHIRA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAHIRA
Middle Name:
Last Name:TANOVIC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 MARCUS AVENUE
Mailing Address - Street 2:SUITE, 103
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1018
Mailing Address - Country:US
Mailing Address - Phone:516-354-1330
Mailing Address - Fax:516-775-5953
Practice Address - Street 1:2500 MARCUS AVENUE
Practice Address - Street 2:SUITE, 103
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042-1018
Practice Address - Country:US
Practice Address - Phone:516-354-1330
Practice Address - Fax:516-775-5953
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-04
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230867208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY230867OtherLICENSE
NY230867OtherLICENSE
I20025Medicare UPIN
1676F1Medicare ID - Type Unspecified