Provider Demographics
NPI:1669587465
Name:TAVERAS, RUSSELL (PT)
Entity type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:TAVERAS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 E MAIN ST
Mailing Address - Street 2:STE I
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-3101
Mailing Address - Country:US
Mailing Address - Phone:631-289-0088
Mailing Address - Fax:631-289-6177
Practice Address - Street 1:79 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3101
Practice Address - Country:US
Practice Address - Phone:631-289-0088
Practice Address - Fax:631-289-6177
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0270991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist