Provider Demographics
NPI:1194160168
Name:TAVANGARI, FAREES RICKY (MD)
Entity type:Individual
Prefix:DR
First Name:FAREES
Middle Name:RICKY
Last Name:TAVANGARI
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:PO BOX 198054
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-8054
Mailing Address - Country:US
Mailing Address - Phone:305-271-9777
Mailing Address - Fax:
Practice Address - Street 1:7800 SW 87TH AVE STE B210
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173-2537
Practice Address - Country:US
Practice Address - Phone:305-271-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-05
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME141205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program