Provider Demographics
NPI:1427058858
Name:TAVOULAREAS, GEORGE PETER (DO)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:PETER
Last Name:TAVOULAREAS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 77TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-2903
Mailing Address - Country:US
Mailing Address - Phone:917-763-4921
Mailing Address - Fax:
Practice Address - Street 1:7402 HOLLISTER AVE
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93117-2583
Practice Address - Country:US
Practice Address - Phone:805-562-8686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010257402084N0400X
IL0361545232084N0008X
IN02006261A2084N0008X
NJ25MB109568002084N0400X
CT671062084N0400X
CA20A185442084N0400X
WI73913-212084N0400X
NY2005662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01663767Medicaid
NMG26514Medicare UPIN
NY509411Medicare ID - Type Unspecified