Provider Demographics
NPI:1679854343
Name:TAVARES PEDIATRICS INC
Entity type:Organization
Organization Name:TAVARES PEDIATRICS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:
Authorized Official - Last Name:AFZAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-394-3929
Mailing Address - Street 1:2754 DORA AVE
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4970
Mailing Address - Country:US
Mailing Address - Phone:352-508-5176
Mailing Address - Fax:352-508-5179
Practice Address - Street 1:2754 DORA AVE
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4970
Practice Address - Country:US
Practice Address - Phone:352-394-3929
Practice Address - Fax:352-394-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME72542261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004771000Medicaid
FL103928Medicare PIN