Provider Demographics
NPI:1386888626
Name:TAVERNARIS, MICHAEL E (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:TAVERNARIS
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 1:208 MARY ESTHER BLVD
Mailing Address - Street 2:
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1687
Mailing Address - Country:US
Mailing Address - Phone:850-396-1110
Mailing Address - Fax:850-466-0950
Practice Address - Street 1:1817 LEWIS TURNER BLVD STE F
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1349
Practice Address - Country:US
Practice Address - Phone:850-396-1110
Practice Address - Fax:850-466-0950
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME116308207QS0010X, 207Q00000X
ALMD31989207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine