Provider Demographics
NPI:1619439213
Name:TAVARES, EMMANUEL JOHN (MD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:JOHN
Last Name:TAVARES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:EMMANUELLE
Other - Middle Name:JOHN
Other - Last Name:TAVARES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 255228
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5228
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 MEDICAL PLAZA DR STE 250
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3089
Practice Address - Country:US
Practice Address - Phone:916-797-4720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA179377208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology