Provider Demographics
NPI:1386242253
Name:TAVAKOLI, KEIVAN A (MD)
Entity type:Individual
Prefix:DR
First Name:KEIVAN
Middle Name:A
Last Name:TAVAKOLI
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 1:153 CALLE EBANO
Mailing Address - Street 2:
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00968-3423
Mailing Address - Country:US
Mailing Address - Phone:703-474-0096
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 364708
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00936-4708
Practice Address - Country:US
Practice Address - Phone:787-758-8383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-13
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLACN1322208D00000X
PR22049208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice