Provider Demographics
NPI:1801895222
Name:TAVARES, SERGIO (MD)
Entity type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:
Last Name:TAVARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 TEXAN TRL
Mailing Address - Street 2:#205
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-2547
Mailing Address - Country:US
Mailing Address - Phone:361-884-7081
Mailing Address - Fax:361-884-5202
Practice Address - Street 1:601 TEXAN TRL
Practice Address - Street 2:#205
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2547
Practice Address - Country:US
Practice Address - Phone:361-884-7081
Practice Address - Fax:361-884-5202
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4411208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00200QMedicare PIN