Provider Demographics
NPI:1740695717
Name:MARINO D. TAVAREZ, MD, MPH PLLC
Entity type:Organization
Organization Name:MARINO D. TAVAREZ, MD, MPH PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARINO
Authorized Official - Middle Name:DE JESUS
Authorized Official - Last Name:TAVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-400-1843
Mailing Address - Street 1:150 JAY ST
Mailing Address - Street 2:FINGER LAKES FAMILY MEDICINE
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-3212
Mailing Address - Country:US
Mailing Address - Phone:315-759-5426
Mailing Address - Fax:585-486-1634
Practice Address - Street 1:150 JAY ST
Practice Address - Street 2:FINGER LAKES FAMILY MEDICINE
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-3212
Practice Address - Country:US
Practice Address - Phone:315-759-5426
Practice Address - Fax:585-486-1634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232852261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02868248Medicaid
NYA400060371Medicare PIN
NYI49841Medicare UPIN