Provider Demographics
NPI:1932554581
Name:TAVAKOLI, CHRISTINE MANDANA (DO)
Entity type:Individual
Prefix:DR
First Name:CHRISTINE
Middle Name:MANDANA
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 1:1940 ENCHANTED WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-0965
Mailing Address - Country:US
Mailing Address - Phone:888-854-1397
Mailing Address - Fax:469-699-0240
Practice Address - Street 1:1940 ENCHANTED WAY STE 101
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051-0965
Practice Address - Country:US
Practice Address - Phone:888-854-1397
Practice Address - Fax:469-699-0240
Is Sole Proprietor?:No
Enumeration Date:2016-05-02
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK6263207Q00000X
TXT3709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine