Provider Demographics
NPI:1831169580
Name:TAVASSOLI, TAGHI (MD)
Entity type:Individual
Prefix:
First Name:TAGHI
Middle Name:
Last Name:TAVASSOLI
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 1:13041 N DEL WEBB BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3034
Mailing Address - Country:US
Mailing Address - Phone:623-977-7201
Mailing Address - Fax:
Practice Address - Street 1:13041 N DEL WEBB BLVD
Practice Address - Street 2:
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85351-3034
Practice Address - Country:US
Practice Address - Phone:623-977-7201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10499208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172122Medicaid
AZ172122Medicaid
AZ102939Medicare ID - Type Unspecified
AZWCKHJ33Medicare ID - Type Unspecified