1942758339 NPI number — JOSEPH TAVERNE M.D.

Table of content: DR. MARY GRACE PURISIMA M.D. (NPI 1003916479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942758339 NPI number — JOSEPH TAVERNE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAVERNE
Provider First Name:
JOSEPH
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942758339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
111 CALLE DR LASSISSE
Provider Second Line Business Mailing Address:
BO PARIS ALTO
Provider Business Mailing Address City Name:
MAYAGUEZ
Provider Business Mailing Address State Name:
PR
Provider Business Mailing Address Postal Code:
00680-5434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-726-9772
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5160 S JOHN YOUNG PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32839-5022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
844-665-4827
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  19476 , registered in the state of PR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208D00000X , with the licence number: ACN1118 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101653600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".