Provider Demographics
NPI:1568040020
Name:TAVAKOLI, TARA SUMMER (DO)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:SUMMER
Last Name:TAVAKOLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 2ND ST E STE 3B
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-1027
Mailing Address - Country:US
Mailing Address - Phone:941-746-4151
Mailing Address - Fax:
Practice Address - Street 1:250 2ND ST E STE 3B
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208-1027
Practice Address - Country:US
Practice Address - Phone:941-746-4151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-29
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS21056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine