Provider Demographics
NPI:1699792275
Name:TAVARES, JEFFREY GERARD (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:GERARD
Last Name:TAVARES
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 1:109 PROSPECT PARK WEST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-3711
Mailing Address - Country:US
Mailing Address - Phone:718-499-5791
Mailing Address - Fax:718-499-5791
Practice Address - Street 1:109 PROSPECT PARK WEST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3711
Practice Address - Country:US
Practice Address - Phone:718-499-5791
Practice Address - Fax:718-499-5791
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18372612084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY78J731Medicare ID - Type Unspecified
F93074Medicare UPIN