Provider Demographics
NPI:1932396645
Name:TAVERAS, GENARO J I (048917)
Entity Type:Individual
Prefix:DR
First Name:GENARO
Middle Name:J
Last Name:TAVERAS
Suffix:I
Gender:M
Credentials:048917
Other - Prefix:
Other - First Name:GENARO
Other - Middle Name:
Other - Last Name:TAVERAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2002 GRAND AV.
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4662
Mailing Address - Country:US
Mailing Address - Phone:718-299-1340
Mailing Address - Fax:718-299-2760
Practice Address - Street 1:2002 GRAND AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4662
Practice Address - Country:US
Practice Address - Phone:718-299-1340
Practice Address - Fax:718-299-2760
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048917122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02152812Medicaid