Provider Demographics
NPI:1811983224
Name:TAVANI, NICHOLAS J (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:TAVANI
Suffix:
Gender:M
Credentials:MD
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Other - Credentials:
Mailing Address - Street 1:9625 SURVEYOR CT
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110-4422
Mailing Address - Country:US
Mailing Address - Phone:703-330-2233
Mailing Address - Fax:703-330-2232
Practice Address - Street 1:9625 SURVEYOR CT
Practice Address - Street 2:SUITE 100
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110-4422
Practice Address - Country:US
Practice Address - Phone:703-330-2233
Practice Address - Fax:703-330-2232
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2013-06-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101044542207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005605601Medicaid
VA005605601Medicaid