Provider Demographics
NPI:1962680090
Name:TAVAREZ, JAIME SR (MT)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:TAVAREZ
Suffix:SR
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 956
Mailing Address - Street 2:
Mailing Address - City:ISABELA
Mailing Address - State:PR
Mailing Address - Zip Code:00662-0956
Mailing Address - Country:US
Mailing Address - Phone:787-872-3480
Mailing Address - Fax:787-872-3480
Practice Address - Street 1:58 CALLE DAGUEY
Practice Address - Street 2:
Practice Address - City:ANASCO
Practice Address - State:PR
Practice Address - Zip Code:00610-2603
Practice Address - Country:US
Practice Address - Phone:787-826-3072
Practice Address - Fax:787-826-3072
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR690291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0038282Medicare UPIN