Provider Demographics
NPI:1558898064
Name:TAVERAS ALCANTARA, MAURO JOSE (MD)
Entity type:Individual
Prefix:
First Name:MAURO
Middle Name:JOSE
Last Name:TAVERAS ALCANTARA
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 2650
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-2650
Mailing Address - Country:US
Mailing Address - Phone:870-541-7211
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:1609 W 40TH AVE STE 403
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6365
Practice Address - Country:US
Practice Address - Phone:870-541-4285
Practice Address - Fax:870-541-4290
Is Sole Proprietor?:No
Enumeration Date:2017-05-15
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.152621207RC0000X
390200000X
ARE-17813207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program