Provider Demographics
NPI:1255512232
Name:TAVARES, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:TAVARES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2230 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-1310
Mailing Address - Country:US
Mailing Address - Phone:916-448-7391
Mailing Address - Fax:916-441-1600
Practice Address - Street 1:2230 9TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-1310
Practice Address - Country:US
Practice Address - Phone:916-448-7391
Practice Address - Fax:916-441-1600
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management